General Summary:

Reviews and assesses appropriateness of patient admission/continued stay.  Works with Financial Case Management Representatives to monitor use of insurance benefits to maximize service to patients.  Provides timely, pertinent insurance benefits information to clinical staff so that they will provide care within patients’ benefits package and thereby optimize third party payment for services.  Assists physicians in preparing appeals when payment has been denied by insurance companies.  Assists in the implementation of the Hospital Utilization Review Plan.  Provides consultation and/or education to clinical staff regarding monitoring studies and medical records reviews.  Represents hospital in involuntary hearings process.  Serves as a member of various clinical committees and provides staff support to committee chairpersons.

Knowledge, Skills, and Abilities Required:

Work requires comprehensive knowledge of a broad range of medical diagnoses, treatment modalities, therapeutic services and intervention techniques, and knowledge of utilization review practices and procedures - acquired through completion of a Bachelor’s degree from an accredited institution in nursing, allied health, records administration, or closely related field. Work requires comprehensive knowledge of patient medical records, health insurance provisions, psychiatric diagnoses, and utilization review practices - acquired through two to three years of related experience.

Benefits:

At Sheppard Pratt, you will work alongside a multi-disciplined team led by a bold vision to change lives. We offer:

A commitment to professional development, including a comprehensive tuition reimbursement program to support ongoing education and licensure and/or certification preparation Comprehensive medical, dental and vision benefits for benefit eligible positions 403b retirement match Generous paid-time-off for benefit eligible positions Complimentary Employee Assistance Program (EAP) Generous mileage reimbursement program

Pay for this position is determined on a number of factors, including but not limited to, years and level of related experience.