The Utilization Review Specialist collects, analyzes, and provides pertinent, timely clinical information to fund sources and external utilization review personnel for authorization of stay and services. The Utilization Review Specialist completes initial, concurrent, and discharge authorizations and reviews through interactions with the patients insurance companies during normal business hours and nights, weekends and holidays as necessary.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Obtain proper prior and ongoing authorization for each patient.
Review and monitor each step of the authorization process to proactively identify and resolve problems.
Interact with physicians and therapists on an on-going basis to assure patient assessment and treatment planning and appropriately gather all clinical information to determine the medical necessity of requested healthcare and to assure services are accurately and consistently reflected in facility documentation.
Maintain a daily record in the Welligent system of the concurrent review process and inform the treatment team of the authorization status of each assigned patient.
Help patients access the full range of their benefits through creative utilization.
Work to extend patients treatment stay as needed or deemed medically appropriate through maximization of benefits and minimizing appeals.
Assess each patients individual needs on the basis of assessment and data collection to ensure proper admission.
Nursing degree from an accredited institution or equivalent combination of knowledge and experience.
Valid Florida Registered Nurse license-preferred
EOE Minorities / Females / Protected Veterans / Disabled