Hunterdon Health
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Utilization Review Specialist
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Hunterdon Health
Job Location and Schedule HHS Hunterdon Healthcare System Inc., 2100 Wescott Drive, Flemington, NJ
One weekend a month and an occasional weekday, Day shift
Employment Type and Compensation Per Diem
Hiring Range: $97,731.66 - $122,164.58 Annually
Req # 78735
Position Summary The Utilization Review Specialist monitors adherence to the hospital's utilization review plan to ensure the effective and efficient use of hospital services and monitors the appropriateness of hospital admissions and extended hospital stays. The evaluation of the appropriateness and medical necessity of health care services, procedures, and facilities is conducted through the application of evidence-based criteria or guidelines, and through authorization/prior authorization under the provisions of an applicable health insurance plan.
Primary Position Responsibilities
Performs utilization activities, using Milliman Care Guidelines under the guidance of the Physician Advisor, to provide clinical information to payors as requested and ensures correct status of all patients to insure maximum reimbursement.
Works with medical and clinical staff to improve overall quality and completeness of clinical documentation.
Communicates and educates medical, clinical and coding staff of trends and opportunities for improvement.
Tracks and trends all queries presented to medical and clinical staff.
Follows department policies to remain in compliance with State and Federal regulations.
Other duties as assigned.
Qualifications Minimum Education
All hires after July 2012 are required to have a Bachelor's Degree in nursing OR if Associate's Degree or Diploma, RN must provide proof of enrollment in a BSN program prior to hire, be continuously enrolled and complete within 5 years of hire date or internal RN promotion date.
Required Experience
Three years of medical/surgical hospital based direct patient care experience.
Preferred Experience
Five years of medical/surgical hospital based direct patient care experience.
Required License/Certification
Current NJ RN Licensure.
Preferred Knowledge, Skills and Abilities
Excellent verbal, written, organizational and interpersonal skills. Demonstrates experience in patient care evaluation methodologies, analysis and reporting of patient clinical data to various payee sources using Milliman Care Guideline criteria sets.
Hunterdon Health is committed to providing a competitive benefit package to our employees. Benefit offerings vary based on status and may include but not be limited to medical, dental, vision, family forming, paid time off, tuition reimbursement, and retirement savings.
The hiring range listed is the potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement. When determining an applicant’s hourly rate and/or base salary, several factors may be considered as applicable (e.g., years of relevant experience, education, internal equity, and specialty).
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Utilization Review Specialist
role at
Hunterdon Health
Job Location and Schedule HHS Hunterdon Healthcare System Inc., 2100 Wescott Drive, Flemington, NJ
One weekend a month and an occasional weekday, Day shift
Employment Type and Compensation Per Diem
Hiring Range: $97,731.66 - $122,164.58 Annually
Req # 78735
Position Summary The Utilization Review Specialist monitors adherence to the hospital's utilization review plan to ensure the effective and efficient use of hospital services and monitors the appropriateness of hospital admissions and extended hospital stays. The evaluation of the appropriateness and medical necessity of health care services, procedures, and facilities is conducted through the application of evidence-based criteria or guidelines, and through authorization/prior authorization under the provisions of an applicable health insurance plan.
Primary Position Responsibilities
Performs utilization activities, using Milliman Care Guidelines under the guidance of the Physician Advisor, to provide clinical information to payors as requested and ensures correct status of all patients to insure maximum reimbursement.
Works with medical and clinical staff to improve overall quality and completeness of clinical documentation.
Communicates and educates medical, clinical and coding staff of trends and opportunities for improvement.
Tracks and trends all queries presented to medical and clinical staff.
Follows department policies to remain in compliance with State and Federal regulations.
Other duties as assigned.
Qualifications Minimum Education
All hires after July 2012 are required to have a Bachelor's Degree in nursing OR if Associate's Degree or Diploma, RN must provide proof of enrollment in a BSN program prior to hire, be continuously enrolled and complete within 5 years of hire date or internal RN promotion date.
Required Experience
Three years of medical/surgical hospital based direct patient care experience.
Preferred Experience
Five years of medical/surgical hospital based direct patient care experience.
Required License/Certification
Current NJ RN Licensure.
Preferred Knowledge, Skills and Abilities
Excellent verbal, written, organizational and interpersonal skills. Demonstrates experience in patient care evaluation methodologies, analysis and reporting of patient clinical data to various payee sources using Milliman Care Guideline criteria sets.
Hunterdon Health is committed to providing a competitive benefit package to our employees. Benefit offerings vary based on status and may include but not be limited to medical, dental, vision, family forming, paid time off, tuition reimbursement, and retirement savings.
The hiring range listed is the potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement. When determining an applicant’s hourly rate and/or base salary, several factors may be considered as applicable (e.g., years of relevant experience, education, internal equity, and specialty).
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