Trinity Healthcare

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at Trinity Healthcare

Posted: 9/25/2019
Job Status: Full Time
Job Reference #: 00125310

Job Description


CH101_65500 Utilization Review

Expected Weekly Hours: 



Position Purpose:

Job Description Details:

Performs utilization review and certifies patient stays by analyzing patient medical records and accompanying physician documentation. Performs concurrent review for proper patient classification and ongoing need for hospitalization, using appropriate criteria.

Using knowledge of medical necessity and appropriateness of setting as gained through a thorough understanding of milliman and interqual criteria, conducts concurrent utilization review. Applies criteria to all observation, inpatient admission and extended stay reviews, meeting all timeframes in order to insure certification of all days; contacts physician for cases not meeting criteria to discuss level of care issues, treatment plan; refers cases not meeting criteria to a physician advisor and follows each case to successful conclusion; reviews caseload to insure all required calls to insurers/third parties are being made; completes caseload daily and completes utilization review abstract according to guidelines. Captures data from special studies, such as avoidable days. Refers problem cases to appropriate supervisor or physician advisor.

Interacts with insurers, third party payors, and review entities such as EQ Health for Medicaid to relay clinical information and to certify inpatient care for payment. Fulfills all requirements for managed care contracted review in order to secure reimbursement and bonus dollars.

Records all interactions in department databases and software such as ALLscripts. Prepares trend reports for select ICUs and patient care areas. Develops and conducts competency reviews in areas pertinent to role, i.e., ur, drug assurance, managed care, and quality screening.

Position Requirements:

Minimum Education:

Required: Bachelors Degree

Specify Degree(s): Nursing

Minimum Experience:

Required: 3-5 years of previous job-related experience



Current Registered Nurse License State of Illinois

Other: Recent (within past 3 years) clinical experience is required for candidates without utilization review and documentation experience. On-the-job training in utilization review and documentation improvement is provided to all staff hired into this position.

Trinity Health's Commitment to Diversity and Inclusion

Trinity Health employs about 133,000 colleagues at dozens of hospitals and hundreds of health centers in 22 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

Trinity Health's dedication to diversity includes a unified workforce (through training and education, recruitment, retention and development), commitment and accountability, communication, community partnerships, and supplier diversity.

Trinity Health is one of the largest multi-institutional Catholic health care delivery systems in the nation. It serves people and communities in 22 states from coast to coast with 93 hospitals, and 120 continuing care locations — including home care, hospice, PACE and senior living facilities - that provide nearly 2.5 million visits annually.

Trinity Health employs more than 120,000 colleagues, including 5,300 employed physicians. Committed to those who are poor and underserved in its communities, we are known for our focus on the country's aging population. As a single, unified ministry, Trinity Health is the innovator of Senior Emergency Departments, the largest not-for-profit provider of home health care services — ranked by number of visits — in the nation, as well as the nation’s leading provider of PACE (Program of All Inclusive Care for the Elderly) based on the number of available programs.

Posted 30+ Days Ago

Full time