Branch Review Specialist conducts branch internal audits to determine whether business controls are sufficient and effectively executed in accordance with bank policies and procedures. Tests established procedures to ensure operational efficiency within branch offices. Being a Branch Review Specialist determines whether branches are performing their planning, accounting, custodial, or business control activities in compliance with management instructions, policies, and procedures. Evaluates functions and activities in assigned areas to determine the nature of operations and the adequacy of systems to achieve established objectives. Additionally, Branch Review Specialist recommends corrective actions and improvements. Requires a bachelor's degree. Typically reports to a supervisor or manager. The Branch Review Specialist occasionally directed in several aspects of the work. Gaining exposure to some of the complex tasks within the job function. To be a Branch Review Specialist typically requires 2 -4 years of related experience. (Copyright 2024 Salary.com)
osition 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
1. 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.
2. Works with medical and clinical staff to improve overall quality and completeness of clinical documentation.
3. Communicates and educates medical, clinical and coding staff of trends and opportunities for improvement.
4. Tracks and trends all queries presented to medical and clinical staff.
Qualifications
Minimum Education:
Required:
All hires after July 2012 are required to have a Bachelor's Degree in nursing OR if Associates 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.
Minimum Years of Experience (Amount, Type and Variation):
Required:
Three years of medical/surgical hospital based direct patient care experience.
Preferred:
Five years of medical/surgical hospital based direct patient care experience.
License, Registry or Certification:
Required:
Current NJ RN Licensure.
Knowledge, Skills and/or Abilities:
Required:
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 Miliman Care Guideline criteria sets.
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