Utilization Review Specialist

Utilization Management Nurse

Location: Not specified

Consistently named best hospital, Lexington Medical Center dedicates itself to providing quality health services that meet the needs of its communities. Ranked in the Columbia metro area by U.S. News & World Report, Lexington Medical Center is the only hospital named one of the Best Places to Work in South Carolina and the first hospital in the state to achieve Magnet with Distinction status for excellence in nursing care.

The 607-bed teaching hospital anchors a health care network that includes six community medical centers and employs more than 8,700 health care professionals. The network includes a cardiovascular program recognized by the American College of Cardiology as South Carolina's first HeartCARE CenterTM and an accredited Cancer Center of Excellence affiliated with MUSC Hollings Cancer Center for research and education. The network also features an occupational health center, the largest skilled nursing facility in the Carolinas, an Alzheimer's care center and nearly 80 physician practices. Its postgraduate medical education programs include family medicine and transitional year.

Job Description:

• Perform admission and concurrent stay medical record review to determine appropriateness of admission, continued stay, and setting.
• Follow patient throughout hospitalization collaborating with attending physician and other health care providers.
• Communicate with third party payors to obtain authorization.
• Contribute to appropriate throughput and length of stay.
• Assist with denial management.
• Review physician medical record documentation and consult with physicians regarding completeness.

Requirements:

• Minimum Education: ADN, Diploma Nursing Degree, or Bachelor of Science in Nursing
• Minimum Years of Experience: 3 Years of experience in an acute care hospital setting
• Required Certifications/Licensure: Registered Nurse currently licensed in the State of South Carolina

Essential Functions:

• Work in a cooperative manner, fostering favorable relations between employees and patients, patients' families, visitors, fellow employees, and the medical staff.
• Exhibit commitment and pride through personal example by positively speaking about LMC, the department, employees, and guests.
• Contribute to teamwork and create harmonious, effective, and positive working relationships with others.
• Respect, understand, and respond with sensitivity to employees and guests by treating others as one would wish to be treated.
• Resolve conflicts and problem-solve by remaining calm when confronted, attempting to identify solutions or referring the person to appropriate authority and attempting to deliver more than is expected.
• Exhibit telephone courtesy by answering promptly with name and department, speaking with a pleasant tone while focusing on the caller, transferring calls correctly and promptly, and attending to calls on hold in a timely manner.
• Maintain confidentiality by discouraging gossip and using discretion when discussing patient, work, or LMC-related information with others.
• Utilize the service recovery process to resolve complaints (GIFT).
• Demonstrate competence in providing duties within role and in providing developmentally appropriate planning/review for patients of all age groups.
• Identify need for professional growth and seek appropriate professional development opportunities, attaining a minimum of 15 hours of continuing education in topics related to the role annually.
• Serve as a role model for other members of the health care team.
• Demonstrate receptiveness to change and flexibility in meeting department needs.
• Assist in orientation and training of staff.
• Perform admission and continued stay medical record review to gather information to support medical necessity of the admission and communicate with third party payors.
• Perform timely review of admissions utilizing InterQual criteria to assess for appropriate level of care assignment. Review both inpatient admissions and patients placed in Observation.
• Incorporate applicable governmental regulatory guidelines in effect for Medicare and/or Medicaid admissions.
• Submit clinical data to third party payors and document authorization in electronic medical record system.
• Perform continued stay reviews based on intensity of service, clinical response to care, expected length of stay, and readiness for discharge, or at intervals