Utilization Specialist-E.D.

Southwest General • Middleburg Heights, OH

13d

About The Position

POSITION INFORMATION Position summary: The utilization specialist in the Emergency Department (ED) will formulate a patient status recommendation for observation or inpatient status, after thorough review of patient assessments during the workup process and collaborate with the ED physicians. This role will also ensure that the daily surgery schedule is up to date and with correct status and coding. Accurate and efficient application of screening criteria will be applied to identify and support patients being placed in the appropriate hospital level of care via emergency, scheduled or direct admission processes. Combines clinical, business, and regulatory knowledge and skill to reduce significant financial risk and exposure caused by concurrent and retrospective denial of payments for services provided. Through continuous assessments, problem identification, and education, the utilization specialist facilitates the quality of health care delivery in the most cost-effective manner. The utilization specialist must be able to demonstrate the knowledge and skills necessary to provide services appropriate to age groups according to specific chronological age, developmental age, and/or psycho-social maturity. The utilization specialist will work collaboratively with management, staff, and departments involved in the patient’s plan of care. The utilization specialist's responsibility is to collect data and clinical review summaries on patients concurrently for both utilization review and quality assessment. The utilization data and clinical summaries are shared with insurance companies to obtain certification of days and prevent denial of payment for services. Utilization specialists will communicate with physicians, hospital staff, outside agencies such as insurance companies, and patients regarding assigned level of care and associated resource utilization.

Requirements

• Graduation from an accredited School of Nursing.
• Minimum of five (5) years of recent experience in clinical nursing or related nursing fields.
• Current licensure by Ohio State Board of Nursing.
• Excellent critical thinking and communication skills
• Strong computer skills

Nice To Haves

• BSN graduate preferred.
• Previous Care Management, Case Management or Utilization Management Experience preferred.
• Previous experience with screening criteria (i.e., Interqual, MCG) preferred.
• ACM/CCM Certification helpful

Responsibilities

• Formulate a patient status recommendation for observation or inpatient status.
• Ensure that the daily surgery schedule is up to date and with correct status and coding.
• Apply screening criteria to identify and support patients being placed in the appropriate hospital level of care.
• Reduce financial risk and exposure caused by denial of payments for services provided.
• Facilitate the quality of health care delivery in the most cost-effective manner.
• Collect data and clinical review summaries on patients concurrently for both utilization review and quality assessment.
• Share utilization data and clinical summaries with insurance companies to obtain certification of days and prevent denial of payment for services.
• Communicate with physicians, hospital staff, outside agencies such as insurance companies, and patients regarding assigned level of care and associated resource utilization.

What This Job Offers

• Education Level: No Education Listed