Job Title

JOB SUMMARY AND SPECIFICATIONSJOB SUMMARYResponsible for reviewing and evaluating the medical record for necessity and appropriateness of healthcare services and treatments before, during and after care. Collaborating with healthcare providers, clinical staff, case managers, insurance companies, clinical coders and patient access staff to ensure the patients are receiving the right level of care per industry standards.MINIMUM QUALIFICATIONSProfessional & Technical SkillsSeveral years of experience in a clinical settingExperience with healthcare information systems and softwareEducationBachelor's degree in nursing, healthcare management, or a related fieldLicense(s) or Certifications(s)Proven experience in utilization management or a related field, with a deep understanding of healthcare delivery systems and payment models. Strong knowledge of medical terminology, diagnostic and procedural coding, and reimbursement methodologies. Excellent analytical and problem-solving skills, with the ability to interpret complex healthcare data and identify trends and patterns. Experience in communication with the ability to liaise effectively with diverse stakeholders, including medical staff, insurance providers, and regulatory agencies. Proficient computer skills, including experience with electronic health record systems and utilization management software. Strong attention to detail and ability to adhere to strict confidentiality guidelines. Sound knowledge of applicable laws, regulations, and accreditation standards related to utilization review. Demonstrated ability to work independently and manage multiple priorities in a fast-paced environment.Other Skills or RequirementsPRN status with Integrated Case Management team. Weekend availability required. Some evenings required. Must work well with a team. Acute care and D/C planning experience preferred.Skilled to Care for Certain Age-Related Patient Groups (incumbents will be skilled in the care of the following patient groups)All age groups