Utilization Review Specialist - RN in Rochester

The Utilization Review Specialist actively participates in the utilization management of patients and evaluating hospital admissions with the use of utilization screening criteria and CMS Guidelines. Actively participates in maximizing accuracy of level of care determinations with the insurance companies in order to reduce denials and increase compliance to hospital with state and federal regulations, and maintain professional standards. The Senior Utilization Review Specialist assists providers with level of care determinations in compliance with regulatory and contractual agreements. The Senior Utilization Review Specialist will act as a mentor and resource for Utilization Review Specialists.

RESPONSIBILITIES

• Uses nationally recognized standards of care guidelines to evaluate hospital admissions to assure the level of care is medically necessary and at the most appropriate level.
• Documents level of care in the clinical review note to support determination.
• Concurrently monitors resource utilization, performing continued stay reviews and assists with managing the length of stay across the continuum.
• Appropriately identifies and refers cases to the Physician Advisor/E H R in order to validate level of care based on medical necessity.
• Concurrently communicates clinical information to payors on severity of illness and intensity of service.
• Manages confidential information in accordance with RRH policy and procedures.
• Actively participates in maximizing accuracy of level of care with the insurance companies in order to reduce denials and increase compliance, while leveraging expertise from the utilization management team.
• Actively participates in analysis of utilization and quality trends and makes recommendations to management on opportunities for improvement.
• Actively participates in Education sessions with Utilization Management, Physician Advisors, Coding, and other stakeholders in order to grow core competencies across the teams.
• Performs other duties as required.
• Perform Auth Certifications and reviews event management as appropriate.
• Perform HINN and CC44 issuance processes.
• Act as a mentor to non-senior Utilization Specialists.

PREFERRED QUALIFICATIONS

• Bachelor’s Degree in Nursing preferred.
• Excellent oral and written communication and interpersonal skills.
• Good understanding of medical management techniques and processes.
• Strong organizational and problem-solving skills.
• Able to adapt and be flexible to changes based on health system needs.
• Knowledge of federal and state regulations (DOH, Medicaid/Medicare).
• Knowledge of third-party payor and/or managed care payment principles helpful.
• Case Management Certification.

REQUIRED QUALIFICATIONS

• Diploma or Associate’s Degree in Nursing required.
• For those hired on or after 7/1/2025, 3 years of acute hospital care, Case Management or Utilization Management experience required.

REQUIRED LICENSURE/CERTIFICATION

• New York State Registered Nurse license.

PHYSICAL REQUIREMENTS

• Medium Work – Exerting 20 to 50 pounds of force occasionally, and/or 10 to 25 pounds of force frequently, and/or greater than negligible up to 10 pounds of force constantly to move objects; Requires frequent walking, standing or squatting.

LICENSES/CERTIFICATIONS

• RN - Registered Nurse - New York State Education Department (NYSED).
• BLS - Basic Life Support - American Heart Association (AHA).

PAY RANGE

$82,742.00 - $113,568.00