Commercial Review Specialist I
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Utilization Management
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State of New York
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T H Util. Review/Quality Assur. Sr Coord., NSSL4
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90573
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UUP (State University Professional Services Unit)
Job Summary:
The UR-CR Specialist I is primarily responsible for ensuring that patient care services are appropriately recorded and utilized in accordance with hospital standards of quality, the policies of regulatory agencies, and the negotiated contracts with reimbursement entities. This is achieved through a thorough chart review and utilization of first-level screening criteria to ensure patients are at the appropriate level of care during the continuum of their hospital stay. The UR-CR 1 will collaborate with the medical team and the UR medical directors to establish the appropriate level of care. The UR CR 1 will act as a liaison for discharge appeals and social admissions, preparing regulatory notices for delivery to the patient
Minimum Qualifications:
NYS Licensed/Registered (or eligible) RN, Bachelor's Degree in Nursing, and a minimum of three years post RN licensure acute care nursing experience, or Associate's Degree in Nursing and five years post RN licensure acute care nursing experience required. Must possess comprehensive and broad knowledge of complex clinical and medical concepts and demonstrate overall proficiency in clinical conceptual understanding for purposes of level of care review. Strong communication skills, both written and verbal, as well as interpersonal skills required for interface and collaboration with leadership, colleagues, providers, Physician Advisors, regulatory agencies, and other health care-related entities are required. Strong organizational skills with the ability to manage assignments and responsibilities in a hybrid work setting, mostly independent, communicating the need for additional support or guidance when necessary. Proficiency in technology use, including PC, Windows, Microsoft applications, Zoom/WebEx platforms, etc.
Preferred Qualifications:
Utilization management or utilization review experience, experience with level of care screening criteria, and CMS regulations as related to hospital admissions. Experience interfacing with health care payers/regulatory agencies.
Work Days:
Monday through Friday, 8 am-4:30 pm, with rotating weekends
Message to Applicants:
Recruitment Office: Human Resources