Utilization Review Specialist

Job Description

ECU Health

About ECU Health Medical Center

ECU Health Medical Center, one of four academic medical centers in North Carolina, is the 974-bed flagship hospital for ECU Health and serves as the primary teaching hospital for The Brody School of Medicine at East Carolina University. ECU Health Medical Center has achieved Magnet® designation twice and provides acute and intermediate care, rehabilitation and outpatient health services to a 29-county region that is home to more than 1.4 million people.

Position Summary

The Utilization Review Specialist will ensure regulatory compliance with CMS Conditions of Participation with regard to Utilization Management. Perform Utiliztion Review according to CMS and commercial payor guidelines. Participate in denial / appeal process.

Responsibilities

• Utilization Management. Utilizes the nursing process to assess, plan, implement and evaluate the utilization management needs for patients in assigned caseload. 
• Performs utilization management activities using approved screening criteria. 
• Provides follow up with appropriate resource for utilization management issues/non-compliance. 
• Coordinates retrospective medical necessity review as identified by internal and external audit, and/or payer denials.
• Advances knowledge and skills in case / utilization management. 
• Collaborates effectively with departmental staff to achieve goals and objectives. 

Minimum Requirements

Associates Degree in Nursing or higher required. NC RN licensure required.

If ADN must have 5 + years experience in an acute care hospital; home health agency; commercial insurance company; case management.

If BSN must have 3-5 years experience in an acute care hospital; home health agency; commercial insurance company; case management.

A certification in Case Management (i.e. CCM, ACM) can substitute for 1 year of experience; Masters Degree in health related field can substitute for 1 year of experience.

Other Information

Shift: Days, Rotating weekends

10 hour shifts (4 days per week).

7:00am to 5:30pm

This position is on-site

General Statement

It is the goal of ECU Health and its entities to employ the most qualified individual who best matches the requirements for the vacant position.

Offers of employment are subject to successful completion of all pre-employment screenings, which may include an occupational health screening, criminal record check, education, reference, and licensure verification.

We value diversity and are proud to be an equal opportunity employer. Decisions of employment are made based on business needs, job requirements and applicant’s qualifications without regard to race, color, religion, gender, national origin, disability status, protected veteran status, genetic information and testing, family and medical leave, sexual orientation, gender identity or expression or any other status protected by law. We prohibit retaliation against individuals who bring forth any complaint, orally or in writing, to the employer, or against any individuals who assist or participate in the investigation of any complaint.