Utilization Review Specialist

Utilization Review Specialist at ECU Health

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

• 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.
• Completes admission and concurrent chart reviews per federal, state or 3rd party payer requirements using screening criteria to determine appropriateness of admission, level of care and continued stay.
• Provides follow up with appropriate resource for utilization management issues/non-compliance.
• Identifies patients who lack medical necessity for initial or continued stay, explains process to attending physician, and modifies patient status to assure appropriate reimbursement.
• Assures notification procedures occur when issues regarding medical necessity arise, such as Letters of Non Coverage.
• Coordinates insurance company appeals related to clinical issues and negotiates as needed to obtain approval and/or facilitate discharge.
• Coordinates retrospective medical necessity review as identified by internal and external audit, and/or payer denials.

• Associate's Degree in Nursing or higher required. NC RN licensure required.
• For ADN: 5+ years experience in an acute care hospital, home health agency, commercial insurance company, or case management.
• For BSN: 3–5 years experience in an acute care hospital, home health agency, commercial insurance company, or case management.
• A certification in Case Management (e.g., CCM, ACM) can substitute for 1 year of experience; a Master's Degree in a health-related field can substitute for 1 year of experience.

Full-time onsite position.

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.

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.