Utilization Review Specialist

Utilization Management Dept.  
Full Time
Day Shift 
7-3:30

Consistently named best hospital, Lexington Medical Center dedicates itself to providing quality health services that meet the needs of its communities. Ranked #1 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 Summary

Performs admission and concurrent stay medical record review to determine appropriateness of admission, continued stay, and setting. Follows patient throughout hospitalization collaborating with attending physician and other health care providers. Communicates with third party payors to obtain authorization. Contributes to appropriate throughput and length of stay. Assists with denial management. Reviews physician medical record documentation and consults with physicians regarding completeness.

Minimum Qualifications

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
Substitutable Education & Experience: None.
Required Certifications/Licensure: Registered Nurse currently licensed in the State of South Carolina
Required Training: None.

Essential Functions

• Works in a cooperative manner, which fosters favorable relations between employees and patients, patients' families, visitors, fellow employees, and the medical staff.  Accepts chain of command, supervision, and constructive criticism.
• Exhibits commitment and pride through personal example by positively speaking about LMC, the department, employees and guests.
• Contributes to teamwork and creates harmonious, effective and positive working relationships with others.
• Respects, understands, and responds with sensitivity to employees and guests by treating others as one would wish to be treated.
• Resolves conflicts and problems-solves by remaining calm when confronted, attempting to identify solutions or referring person to appropriate authority and attempting to deliver more than is expected.
• Exhibits telephone courtesy by:          
  • Answering promptly with name and department.       
  • Speaking with pleasant tone while focusing on caller.      
  • Transferring calls correctly and promptly.        
  • Attending to calls on hold in a timely manner.
• Maintains confidentiality by:           
  • Discouraging gossip.           
  • Using discretion when discussing patient, work, or LMC-related information with others.
• Utilizes the service recovery process to resolve complaints (GIFT).
• Demonstrates competence in providing duties within role.
• Demonstrates competence to provide developmentally appropriate planning/review for patients of all age groups.
• Identifies need for professional growth and seeks appropriate professional development opportunities attaining a minimum of 15 hours of continuing education in topics related to the role annually.
• Serves as role model for other members of the health care team.
• Demonstrates receptiveness to change and flexibility in meeting department needs.
• Assists in orientation and training of staff.
• Performs admission and continued stay medical record review to gather information to support medical necessity of the admission and communicate with third party payors.
• Performs timely review of admissions utilizing InterQual criteria to assess for appropriate level of care assignment.  Reviews both inpatient admissions and patients placed in Observation.
• Incorporates applicable governmental regulatory guidelines in effect for Medicare and/or Medicaid admissions.
• Submits clinical data to third party payors and documents authorization in electronic medical record system.
• Performs continued stay reviews based on intensity of service, clinical respo