Utilization Review Specialist

Spectrum Health   St Joseph, MI   Full-time
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Job Description

Job Summary

Provides health information, interacts and acts as a resource for nursing units for complex clinical situations to ensure appropriate use of acute care services and diagnosis-related group (DRG) management. Assesses appropriateness of inpatient admissions and continued stay. Educates medical staff/other health care professionals regarding utilization management and quality requirements. Makes recommendations and provides financial and utilization management (UM) information to other members of the care facilitation teams for work prioritization. Works closely with Inpatient Care Facilitators and Medical Social Workers to move patients through the continuum appropriately.

Essential Functions

  • Assesses and interprets clinical information and assists in case management of complex patient population, through use of independent judgment, mature problem solving skills, and guidelines for appropriateness of acute care setting upon admission and continued stay.
  • Assists with adjustment on patient registration status code, as needed, to maximize reimbursement and be consistent with regulatory standards.
  • Communicates with physicians, medical social workers, field staff and other hospital personnel concerning change in level of care on the medically complex patient population. Makes recommendations and discusses alternatives. Provides financial/DRG, UM, health information to other facilitation team members for work prioritization. Communicates and collaborates with physicians and members of the team to ensure continuity and coordination of services.
  • Documents any instances where services were delayed, inappropriate, refused, complicated, etc. for resource management functions.
  • Identifies quality indicators to facilitate process improvement and physician education.

Qualifications
  • Required Associate's Degree
  • Skills/knowledge/abilities typically gained through less than two years related experience in utilization management, discharge planning, designing patient centered care plan, or related work Required
  • LIC-Master Social Worker (MSW-Master) - STATE_MI State of Michigan OR
  • LIC-Registered Nurse State of Michigan

    Primary Location

    SITE - Lakeland Medical Center - 1234 Napier Ave - St Joseph

    Department Name

    Behavioral Health - St Joseph

    Employment Type

    Full time

    Shift

    Weekly Scheduled Hours

    40

    Hours of Work

    40

    Days Worked

    5

    Weekend Frequency

    N/A

    Spectrum Health requires all team members to receive the COVID-19 vaccinations subject to certain exclusions based on the team member’s job category. Spectrum Health is committed to granting reasonable accommodations in accordance with applicable laws.

    Accommodation Notice: If you are a qualified individual with a disability, you may request a reasonable accommodation in Spectrum Health's application process. Contact us at 616-486-SHHR (7447).

    Spectrum Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, sexual orientation, veteran status, or any other legally protected

    category. See more here.

    This job is no longer available.

    Spectrum Health

    St Joseph, MI