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Registered Nurse - Utilization Review Specialist

Company: Rochester General Health System
Location: Rochester
Posted on: January 26, 2023

Job Description:


As a Registered Nurse - Utilization Review Specialist, your strong attention to detail, knowledge of regulations and exceptional evaluation skills lead you to accurately determine necessary levels of care, reducing denials and increasing compliance.

STATUS: Full Time

LOCATION: Rochester General Hospital

DEPARTMENT: Physician Advisor / Utilization Review

SCHEDULE: Currently Monday - Friday, Days with potential

Days / Evenings, Every 4th weekend, Holidays (weekends, evenings and holidays currently on hold)


* Three (3) years of acute hospital care, case management or utilization management experience
* Knowledge of federal and state regulations (DOH, Medicaid/Medicare)
* Knowledge of third party payor and/or managed care payment principles helpful
* Excellent communication and interpersonal skills
* Strong understanding of medical management techniques and processes
* Strong organizational and problem-solving skills
* Ability to adapt and be flexible to changes based on health system needs


* Level of Care Management. Use nationally recognized standards of care guidelines to evaluate hospital admissions and assure the level of care is medically necessary and at the most appropriate level; concurrently monitor resource utilization, perform continued stay reviews and assist with managing the length of stay across the continuum; analyze utilization and quality trends and make recommendations to management on improvement opportunities
* Documentation & Referral. Document level of care in the clinical review note to support determination; appropriately identify and refer cases to the Physician Advisor/EHR, in order to validate level of care based on medical necessity

Keywords: Rochester General Health System, Rochester , Registered Nurse - Utilization Review Specialist, Healthcare , Rochester, New York

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