Working remotely out of the home office, the Utilization Review Specialist assumes responsibility and accountability for admission and concurrent reviews assuring the prevention of denials from all payers, as well as appeals of all accounts reviewed and deemed appropriate for appeal. The Specialist will create a structure for resolution of root cause denial trends by continuously working to identify opportunities for workflow improvements.
This RN professional works in partnership within the interdisciplinary team to achieve optimal clinical outcomes, and facilitates post hospital services as needed.
Experience, Knowledge and Abilities
Current unencumbered state RN license; Case Management certification preferred;
3 + years’ experience in utilization review;
Outstanding interpersonal skills to effectively communicate with physicians, patients/families, healthcare team, administration, community and third party payers;
Proven track record in problem-solving, critical thinking as well as the ability to work effectively under pressure, adapt to fluctuating workloads, and use independent judgment;
Ability to abstract and analyze data regarding utilization, quality and outcomes;
Ability to influence decisions, gain cooperation, and facilitate change with all health care providers, patients, and families;
Solid working knowledge of Medicare, QIO, The Joint Commission, Medicaid and other regulatory agency requirements as well as other private third party payer requirements.
About Vista Health System
Vista Health System includes a full-service community hospital, as well as diagnostic, therapeutic and physician practices throughout our community. We also employ a team of remote professionals who add value from across the country. Although our system has grown over time, our services have been part of Lake County, IL for over 100 years. Please visit our website for more information about our growth and progress at www.vistahealth.com.
We offer a competitive salary and benefits packages which includes: Medical PPO Insurance Dental, Vision, Company Paid Life and AD&D Insurance, Supplemental Life, Spouse/Dependent Life, Short Term Disability, Long Term Disability, Flexible Spending Accounts, Employee Assistance Program, Education Assistance, 401(k) Retirement Savings Program, Paid Time Off, Paid Sick Leave, Scholarship Program, and various company discounts.