Utilization Review Specialist Job Description

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Author: Artie
Published: 23 Aug 2021

Utilization Review Specialists: A Career in Health Care, Internal Utilization Review in Medicare and Medicaid, Utilization Review Nurses, The Difference Between Utilization Review and UM Management and more about utilization review specialist job. Get more data about utilization review specialist job for your career planning.

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Utilization Review Specialists: A Career in Health Care

The specialists assess plans for patient care and determine what treatment is most cost-effective. They investigate disputed medical claims, coordinate utilization training for the medical staff, analyze electronic medical records, and inform medical staff if a claim is denied, approved, or under appeal. The utilization review specialist can be an advocate for quality patient care, cost reduction, and hospital quality standards.

Many employers prefer utilization review specialists who have an associate or bachelor's degree in a medical or health related field, though some may consider candidates without a degree who have extensive experience in medical billing and health care quality assurance roles. Medical professionals, such as nurses, EMTs, and medical technicians, are often sought by health care organizations to transition into utilization review specialist positions. You must know how to interpret medical records and coding.

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Internal Utilization Review in Medicare and Medicaid

The goal of utilization review is to make sure patients get the care they need, that it is administered via proven methods, and delivered in an appropriate setting. Hospitals are required to have an effective utilization review program in order to participate in Medicare and Medicaid. Drug utilization review protocols are in place for both Medicare and Medicaid to reduce abuse and misuse of certain medications.

While the care is being given, concurrent UR, or after the care has been completed, retrospective UR, utilization review can be done. When a patient needs approval from their health insurer before a test or treatment can be performed, prospective utilization reviews can be done. Hospitals tend to have robust internal utilization review protocols because they want to avoid claim denials in the first place by making sure that the care they're providing is appropriate, efficient, and linked to improved patient outcomes.

Utilization Review Nurses

The utilization review nurses perform a number of tasks, including checking medical records, speaking with patients and care providers, and responding to the plan of care. They make recommendations regarding the care of identified diagnoses based on the research results. They help with determining whether a treatment meets the criteria for reimbursement by the insurance plan.

discharge planning roles include utilization review nurses who are there to make sure patients make a safe transition from acute to home care. Pre-certification is when they determine if a procedure, medication, or therapy is appropriate for an individual according to the guidelines of their insurance plan. The minimum credentials for utilization review are being licensed as a registered nurse and having a good base of general nursing experience.

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The Difference Between Utilization Review and UM Management

Understanding the difference between Utilization Review and Utilization Management is very important in the healthcare continuum. The processes and meanings of the two terms are very different. Their differences make a difference.

Practicing Utilization Review: A Free Facebook Group for Practitioners

In order to confirm that therapy services being delivered are actually covered by the healthcare plan, insurance companies use utilization review. Anyone going into utilization review should care about the use of benefits being done ethically and minimally. You need to understand the true value of a patient.

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It is possible to get a license to practice. It is necessary to have worked in the field for at least a year to become a utilization review nurse. A nurse who focuses on cancer patients has the knowledge and experience necessary to accurately review their records. Utilization review nurses come from a variety of nursing careers and may be familiar with specific patient populations.

Precertification in Workers' Compensation

Precertification is a part of the medical management utilization review process in a workers' compensation claim. Precertifcation is the most basic level of determining the medical necessity. Precertifcation is the process in which a workers' compensation carrier can either pre-approve or deny medical procedures or treatments before they are rendered and paid for.

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