Job Description
Regional Utilization Review Documentation Specialist (RN) at TrinityHealth summary:
The Regional Utilization Review Documentation Specialist (RN) coordinates with healthcare teams and insurance payers to ensure patients receive appropriate, cost-effective care across multiple hospitals in Illinois. They conduct clinical reviews, verify authorization statuses, and manage discharge processes while adhering to regulatory and payer requirements. This role involves collaborating with physicians and administrative staff to optimize patient care delivery and support utilization management initiatives.
Employment Type: Full time
Shift: Day Shift
Description: Utilization Review- RN Reviewer- Regional Coverage for Loyola, Gottlieb and MacNeal Hospitals.
Utilization Review- RN Reviewer- Regional Coverage for Loyola, Gottlieb and MacNeal Hospitals.
**Position will be responsible for Gottlieb Memorial Hospital, Loyola University Medical Center, and MacNeal Hospital. Office location is Loyola campus. Position is hybrid, must reside in Illinois.
The
Regional Utilization Review Documentation Specialist nurse works with the multidisciplinary team including physicians, staff and payers to ensure patient's progress along the continuum of care in an efficient and cost-effective manner that ensures quality outcomes. They utilize established guidelines to support appropriate level of care throughout hospitalization. They serve as a liaison between the hospital and external payers on issues related to severity of illness and intensity of service for patients to ensure appropriate and timely utilization of hospital services. This position will reflect a regional coverage. The position includes but not limited to basic UR job duties such as level of care determination, clinical submission to payers, timely following/securing of auth payer status, timely discharge notification, monitoring status of procedural cases and submitting/monitoring post acute authorization status.
Admission and Concurrent Case Review:
- Uses approved criteria for admission and continued stay reviews to ensure appropriate setting and timely implementation of plan of care.
- Monitors patient's progress across the continuum and intervenes as necessary to ensure quality services that are efficient and cost effective.
- Collaborates with admitting physician regarding appropriate level of care/status determination.
- Consults with Physician Advisor and administrative leadership as necessary for those patients not meeting medical necessary services for acute care.
- Knowledgeable of Medicare, Medicaid and non-governmental payer regulations for patient care requirements.
- Responds to requested insurance reviews based on contractual obligations.
- Actively manages concurrent denials.
- Reports data per request of the appropriate leadership for information and resolution, which may include risk management, epidemiology, payer requirements, and performance improvement departments.
- Complete timely discharges and final authorization status to ensure alignment of payer auth and claim submission.
Regulatory and Contractual Compliance:
- Demonstrates service excellence by providing complete clinical information to government and non-governmental review organizations following HIPAA guidelines.
- Identify and document appropriate necessary changes in level of care.
- Partners with Care Management for Medicare patients disputing their discharge.
- Delivery of Detailed Notice of Discharge and transmission of medical records to the QIO within required timeframes.
- Partners with Care Management for delivery of any regulatory documentation.
- Documents all pertinent communication regarding certification in clinical database.
- Timely submission of all initial, concurrent and discharge reviews.
- Serves as a resource to the healthcare team regarding utilization standards and potential alternatives to acute care hospitalization.
- Evaluate hospitalized patients to make sure they are receiving services in the most appropriate and cost - effective setting in collaboration with attending physicians.
- Actively participates in the Utilization Management committee.
- Additional responsibilities as needed.
We offer our employees: - Benefits from Day One
- Competitive compensation
- Career Development
- Tuition Reimbursement
- On Site Fitness Center
- Educational Stipend
- Referral rewards
Our Promise to You: Joining Loyola Medicine is being a part of an organization that treats the human spirit in our patients and in our colleagues. We are a part of a community which believes in giving back to those we serve.
We seek colleagues with: - Bachelor's degree in Nursing; Master's degree preferred.
- 3-5 years of previous job-related experience required.
- 6-10 years of previous job-related experience preferred.
- Strong clinical background is necessary.
- Clinical experience in medicine, surgery, critical care, telemetry, or ED is required.
- Recent UR experience is highly preferred.
- Excellent organizational, time management, typing and communication skills are necessary.
- Current Registered Nurse License State of Illinois
- Specialty certification in clinical or functional area of nursing granted by a national nursing organization preferred.
- Case Management certification expected within 2 years of hire.
Pay Range: $78,540.80 - $121,721.60 per year
Actual compensation will fall within the range but may vary based on factors such as experience, qualifications, education, location, licensure, certification requirements, and comparisons to colleagues in similar roles.
Trinity Health Benefits Summary
Our Commitment Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.
Keywords:
utilization review, registered nurse, clinical documentation, patient care coordination, insurance authorization, discharge planning, healthcare compliance, case management, hospital utilization, payer liaison
Job Tags
Full time, Work at office, Local area, Shift work, Day shift,