Utilization Review Coordinator jobs in Springfield, IL

Overview

As a Utilization Review Nurse, you will work under the direct supervision of the Supervisor, Utilization Review and Clinical Documentation Improvement, this role will be responsible for providing clinically based concurrent and retrospective review of inpatient medical records to evaluate the documentation and utilization of acute care services. This includes facilitation of appropriate physician documentation of care to accurately reflect patient severity of illness and risk of mortality.

Additionally, this role will be responsible for performing utilization review of all patients presenting for hospitalization to assist in identifying patients appropriate for admission to inpatient, observation, or other patient care status. This position conducts continued stay review evaluating the medical necessity, appropriateness and efficient use of health care services of all hospitalizations (inpatient & outpatient). This role will collaborate with the health care team to optimally certify the level of care.

Qualifications

Education:

• Associates Degree in Nursing. Bachelor’s Degree in Nursing preferred.
• Evidence of continuing professional development.Licensure/Certification/Registry:
• Current RN licensure in the State of Illinois required.

Experience:

• Minimum three years’ recent hospital based patient care
• Minimum one (1) year experience with Milliman and/ or InterQual
• HMO, managed care, PPO, Utilization Management experience preferred

Other Knowledge/Skills/Abilities:

• Demonstrate proficiency with use of Conditional Code 44, HINN, and Medicare Important Message
• Familiarity with coding concepts and coding software desired.
• Knowledge of care delivery documentation systems and related medical record documents
• Knowledge of age-specific needs and the elements of disease processes and related procedures
• Strong broad based clinical knowledge and understanding of disease processes
• Knowledge and skill in the use of computer software applications for drafting documents, data management, and tracking, especially those programs used by Passavant Area Hospital (PAH).
• Excellent communication, interpersonal, and organizational skills

Responsibilities