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CRM Utilization Review Specialist
Category: Other
  • Your pay will be discussed at your interview

Job code: lhw-e0-90664093

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Riverside HealthCare

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  Job posted:   Thu Jun 7, 2018
  Distance to work:   ? miles
  3 Views, 0 Applications  
CRM Utilization Review Specialist

The CRM Utilization Review Specialist will conduct concurrent medical record review for medical necessity and level of care using nationally recognized acute care indicators and criteria as approved by medical staff, CMS, and other state and regulatory bodies. Prospectively or concurrently determines the appropriateness of inpatient or observation services following relevent medical documentation, medical guidelines and insurance benefits and communicates information to payers in accordance with contractual obligations. Serve as a resource to the physicians and provide education and information on resource utilization, national and local coverage determinations, and user of InterQual.



Admission reviews are done concurrently in cooperation with AURS to determine the appropriateness of hospital level care.

Collaborate with community physicians and hospitalist to influence appropriate utilization of resources, accurate status determination, and transitions from one level of care to another.

Collaborate with other clinical team members in reviewing actual and proposed medical care and services against established CMS coverage guidelines review criteria.

Collaborates to provide accurate and complete clinical information relative to obtaining precertification/authorization.

Collaborates with PFS in the denial appeals process as part of the revenue cycle.

Confers with attending physician and physician advisor if inappropriate inpatient treatment is contemplated and issues HINN-11 if not resolved.

Consults with medical advisor as necessary to resolve progression-of-care barriers through appropriate administrative and medical channels.

Educates members of the patient's healthcare team on the appropriate access to, and use of various levels of care.

Encourage healthcare team members in collaborative problem solving acting regarding appropriate use of resources.

Establishes and maintains effective professional working relationships with patients, families, interdisciplinary team members, payers, and external case managers.

Identify and record episodes of preventable delays or avoidable days due to failure of progression-of-care processes.

Identify potentially unnecessary services and care delivery settings and recommend alternatives if appropriate by analyzing clinical protocols.

Keeps current on all regulatory changes that affect delivery of reimbursement of acute care services.

Other duties as assigned.

Pro-actively participates as a member of the interdisciplinary clinical team to confirm appropriateness of the treatment plan relative to the patient's preference, reason for admission, and availability of resources.

Promote use of evidence-based protocols and/or order sets to influence high quality and cost effective care.

Recognizes and responds appropriately to patient risk factors.

Reviews OR schedule 24 hours in advance to confirm admission status.

Serves as a resource person to physician, case managers, physician offices, and billing office for coverage and compliance issues.

Uses guidelines to determine appropriateness for inpatient level of care or observation services based on documented severity of illness and intensity of services.


Experience/Education Requirements:Graduate of an approved school of nursing, BSN preferred. As of 1/1/18, must complete BSN within 4 years of hire or transfer.Expert knowledge of InterQual Level of Care Criteria and/or Milliman Care Guidelines and knowledge of local and national coverage determinationsRecent work experience in the hospital or insurance industryFamiliarity with SIMS procedure indicators and inpatient only listings preferred

License or Certification Requirements:Current RN license in the state of IllinoisCertification as a Certified Professional Utilization Review (CPUM) or Certified Professional Utilization Management (CPUR) preferred within 3 years of employment


Job ID2018-17237

# of Openings1


TypePRN/TR (As Needed)


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