Utilization Review Specialist

Originally posted by Mazzi

What is an Untilization Review Specialist? Where do they work? Who hires them? I hear this term used around the medical community but have never met anyone that works in this field. Please ease my curiousity.

A Utilization Review Specialist is a nurse who conducts reviews for appropriateness of hospital stays via precert, concurrently or retrospectively. She may also be asked to assist with discharge plans (depending on where he/she is working), which may be either for a insurance company or in the hospital setting itsellf.

A Utilization Review Specialist is a nurse who conducts reviews for appropriateness of hospital stays via precert, concurrently or retrospectively. She may also be asked to assist with discharge plans (depending on where he/she is working), which may be either for a insurance company or in the hospital setting itsellf.

Can you tell me more about it? How can I learn the medicare codes, etc?

... a nurse who conducts reviews for appropriateness of hospital stays via precert, concurrently or retrospectively... may also be asked to assist with discharge plans... either for a insurance company or in the hospital setting itsellf.

Concise and correct.

Recently, I interviewed for a job as a Concurrent Review Nurse. Here is the posting (with the city info removed):

--------- posting -------

RN Concurrent Review Coordinator

Accepting Applications and Interviewing

The Utilization Management Department has a full time, exempt opening for a Concurrent Review Coordinator. This position will conduct and coordinate concurrent review activities; research and problem solve complex patient care issues and maintain working relationships with physicians and hospital staff. Develop and implement effective screening processes to identify members who may benefit from case management, including those with catastrophic or complex diagnosis, deteriorating illness, specific disease states or situation complications. Facilitate appropriate access to the health care system by identifying resources and service options; conduct assessments on candidates by reviewing treatment plans and other information. Develop and monitor comprehensive treatment plans and implement and coordinate specific goals. Requires Bachelors degree in nursing and 5 years of progressive nursing experience with case management in a managed care setting. Working knowledge of case management concepts, community resources, benefits systems, physical and psychological factors and coordination and service delivery experience required.

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I thought the verbage was rather similiar to Utilization Review Nurse.

I did NOT take the postion because (thank goodness) the team made it clear that I was expected to work OT on demand (without extra pay as I was salaried), and flex time was NOT an option that was reasonably predictable (I have kids in sports).

Hope this helps or adds to the conversation.

night