R1 is the leading provider of technology-driven solutions that transform the patient experience and financial performance of hospitals, health systems and medical groups. We are the one company that combines the deep expertise of a global workforce of revenue cycle professionals with the industry’s most advanced technology platform, encompassing sophisticated analytics, AI, intelligent automation, and workflow orchestration.
The Utilization Review Specialist will be part of our Physician Advisory Team providing first level initial admission and continued stay case reviews. The Utilization Review Specialist will determine the appropriate cases for review, utilizing client specific guidelines. Upon identification of a case, the Utilization Review Specialist will ensure that appropriate orders and clinical documentation is in place prior to application of the evidence-based criteria.
Responsibilities:
Perform initial admission and continued stay reviews utilizing InterQual and MCG using evidenced-based criteria to identify and support the appropriate level of care
Abstract data from a variety of medical records to ensure accurate clinical data
Adhere to established quality, timeliness, and productivity outputs required in the completion of first level nursing utilization review
Ensure effective communication internally and externally while delivering excellent customer service
Perform other duties as assigned by departmental leadership in support of departmental and organizational strategies and goals which may include system testing, training and other opportunities that promote growth
Complete and maintain annual compliance and annual HIPAA training
Participate in organizational educational offerings and required training as needed to support service delivery
Required Qualifications:
Bachelor’s Degree
Must have a current Registered Nurse license
2 years of recent hospital-based Utilization Review preferred
At least 3 years of clinical nursing experience (practice)
Knowledge of current Medicare rules and regulations related to Utilization Review
Strong analytical, organizational and time management skills
Ability to work independently with limited supervision
Excellent clinical abstraction and attention to detail
Experience with InterQual and/or MCG is preferred
Must be willing to work a variable schedule that encompasses evenings, days, weekends, and holidays. Hiring day shift: 8am-4pm and night shift 4pm-12am. Also, must be able to work 4 weekend days a month.
For this US-based position, the base pay range is $65,500.00 – $96,885.29 per year . Individual pay is determined by role, level, location, job-related skills, experience, and relevant education or training.
This job is eligible to participate in our annual bonus plan at a target of 10.00%
The healthcare system is always evolving — and it’s up to us to use our shared expertise to find new solutions that can keep up. On our growing team you’ll find the opportunity to constantly learn, collaborate across groups and explore new paths for your career.
Our associates are given the chance to contribute, think boldly and create meaningful work that makes a difference in the communities we serve around the world. We go beyond expectations in everything we do. Not only does that drive customer success and improve patient care, but that same enthusiasm is applied to giving back to the community and taking care of our team — including offering a “>California Consent
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