PAS Utilization Review Author

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.