POSITION PURPOSE: The Utilization Review Specialist is responsible for assisting in the facilitation of critical criteria reviews on patients for behavioral medicine admissions and continued stays, completion of certifications/interfaces with managed care organizations, external reviewers and other payers.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

1. Maintains recognition and acceptance of accountability and responsibility for duties and functions within the scope of the practice of the RN; collaboration with other team members towards problem resolution; precise and appropriate verbal and written communication; and behaviors consistent with the role of the professional nurse.
2. Reviews patients medical records to collect data pertaining to diagnoses and major procedures performed, evaluates appropriateness of admission, observation and length of stay, and completes required forms.
3. Reviews patients medical records for particular aspects of care (as directed) and/or problems which adversely affect patient care.
4. Performs concurrent reviews of admissions to determine medical necessity for admission, observation and continued stays. Refers those that do not meet criteria to the Physician Advisor and/or Department Chairman.
5. Performs concurrent reviews for the appropriateness of resource consumption and refers any over or under utilization to the Physician Advisor.
6. Reviews specific incidents and utilization problems with Physician Advisor such as extended hospital stays, complications with care, and patients waiting for placement.
7. Conducts ongoing utilization review for compliance with approved third-party treatment plan and ensures necessary interventions. Communicates with payors regarding clinical updates and the need for continued hospitalization.
8. Follows through on the assessment of the RN Case Manager for discharge planning and educational needs in the absence of that case manager; plans the patients care and ensures that patient family teaching is complete.
9. Consistently supports the hospitals Spirit of Serving Standards, in line with the Mission, Vision and values of St. Joseph Medical Center.
10. Supportive of the compliance program set forth by SJMC and demonstrated by:
    • Upholds the Code of Ethics and Corporate Compliance.
    • Adheres to and helps to enforce all compliance policies relevant to his/her area.
    • Assures timely compliance education as requested by the Compliance Officer and/or through corporate initiatives.
11. Sets an example to all staff in their daily activities.

WORK EXPERIENCE:

• Three (3) years experience as a Clinical Nurse, proficient in clinical and technical skills in nursing specialty; leadership and teaching skills in order to gain a full understanding of case management practices and procedures.

LICENSE/REGISTRATION/CERTIFICATION:

• Current RN licensure issued by the Board of Nurse Examiners issued by the State of Texas.

EDUCATION & TRAINING:

• Bachelors Degree in Nursing from an accredited School of Nursing.

SKILLS:

• Technical, critical thinking, and interpersonal skills relevant to clinical area in order to effectively communicate with patients and physicians.
• Knowledge of criteria used to assess medical necessity and appropriateness of hospitalization and continued care.
• Ability to speak clearly enabling patients and others easy comprehension.
• Ability to write and print legibly.
• Demonstration of customer focused skills.