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ST. CHARLES HEALTH SYSTEM

JOB DESCRIPTION

TITLE: Utilization Review Specialist

REPORTS TO POSITION: Manager - Utilization Management

DEPARTMENT: Utilization Management

DATE LAST REVIEWED: August 2025

OUR VISION: Creating America's healthiest community, together

OUR MISSION: In the spirit of love and compassion, better health, better care, better value

OUR VALUES: Accountability, Caring and Teamwork

DEPARTMENTAL SUMMARY: The Utilization Management (UM) Department promotes and provides a centralized, collaborative multi-disciplinary approach to utilization management across St. Charles Health System. The UM Department supports physicians and clinical staff in identifying and improving care processes and systems for establishing and ensuring medical necessity, appropriate utilization of services, supporting denial avoidance and recovery and compliance with all local, state, and federal regulations.

POSITION OVERVIEW: The Utilization Review Specialist works under the direction of the Utilization Management Manager and acts as an interdisciplinary team member within the Utilization Management Department.

The Utilization Review Specialist is responsible for providing verification of benefits, authorization procurement and other assigned tasks. In addition, the Utilization Review Specialist is responsible for collaborating with the UM RN and other members of the interdisciplinary team (i.e. Physicians, Case Managers, Social Workers, etc.) or interdependent departments (i.e. Patient Access, Billing, etc.) to avoid unnecessary delays in patient care, discharge, or billing.

The Utilization Review Specialist will serve as the first point of escalation for payors requiring assistance in gaining additional or missing information to support authorization. The Utilization Review Specialist is responsible for ensuring procurement of authorization upon admission, discharge, and accuracy of authorization information. In addition, the Utilization Review Specialist ensures timely escalation of barriers to authorization requiring clinical expertise and assist in coordination of Peer to Peer discussions with the payor.

This position does not directly supervise any other caregivers.

ESSENTIAL FUNCTIONS AND DUTIES:

Acts as interdisciplinary team member within the Utilization Management (UM) department.

Accurately completes assigned (triaged by UMS) requests submitted from payors; promptly escalates cases requiring clinical expertise to UM RN and / or multidisciplinary team.

Escalates Medical Necessity (patient status / LOC) concerns and other UM concerns to the Physician Advisor.

Submits clinical reviews to payors. Submits clinical information supporting admission, continued stay reviews, and provides discharge information to payors upon request.

Identifies and escalates all 1MN Medicare and 2MN Obs stays for review at committee through use of assigned work queues.

Reviews and addresses all discharged encounters pending payor authorization follow-up (i.e. additional authorized days, authorization accuracy).

Maintains a working knowledge of UM specific changes (i.e. changes in authorizations, payor contracts, CMS, and regulatory requirements).

Prepares and facilitates the delivery of regulatory notices and ensures compliance with payor regulations.

Supports clinical denials and appeals processes, both concurrent and post claim.

Supports peer to peer workflows and the discharge appeal process.

Collaborates with the Case Management and Social Work teams (i.e. extended observation stays, patients no longer meeting medical necessity, status changes).

Communicates and collaborates with Patient Access, Patient Financial Services (PFS) and Health Information Management (HIM).

Provides timely and continual coverage of assigned work area to ensure all accounts are complete.

Documents all interactions with patient, family / caregiver, and patient's care team.

Complies with all documentation requirements.

Follows up on action items prior to the end of shift and completes all tasks within department guidelines.

Adheres to the policies, procedures, rules, regulations, and laws of the hospital and federal and state governing bodies.

Assists Department Manager with quality audits.

Participates in tracking of departmental quality measures by abstracting and reporting UM data.

Supports the vision, mission and values of the organization in all respects.

Supports Value Improvement Practice (VIP- Lean) principles of continuous improvement with energy and enthusiasm, functioning as a champion of change.

Provides and maintains a safe environment for caregivers, patients and guests.

Conducts all activities with the highest standards of professionalism and confidentiality. Complies with all applicable laws, regulations, policies and procedures, supporting the organization's corporate integrity efforts by acting in an ethical and appropriate manner, reporting known or suspected violations of applicable rules, and cooperating fully with all organizational investigations and proceedings.

Delivers customer service and/or patient care in a manner that promotes goodwill, is timely, efficient and accurate.

May perform additional duties of similar complexity within the organization, as required or assigned.

EDUCATION

Required: Associate degree or higher in Health Information Management.

Preferred: N/A

LICENSURE/CERTIFICATION/REGISTRATION

Required: Current RHIT

EXPERIENCE

Required: 1 year experience in similar hospital related position in Health Information Management

Preferred: N/A

PERSONAL PROTECTIVE EQUIPMENT

Must be able to wear appropriate Personal Protective Equipment (PPE) required to perform the job safely.

ADDITIONAL POSITION INFORMATION

General:

Must have excellent communication skills and ability to interact with a diverse population and professionally represent St. Charles Health System.

Ability to effectively interact and communicate with all levels within SCHS and external customers/clients/potential employees.

Strong team working and collaborative skills.

Ability to multi-task and work independently.

Attention to detail.

Excellent organizational skills, written and oral communication and customer service skills, particularly in dealing with stressful personal interactions.

Strong analytical, problem solving and decision-making skills.

Intermediate to advanced proficiency in Microsoft applications (Word, Excel and Access), database management, and document preparation.

PHYSICAL REQUIREMENTS:

Continually (75% or more): Use of clear and audible speaking voice and the ability to hear normal speech level.

Frequently (50%): Sitting, standing, walking, lifting 1-10 pounds, keyboard operation.

Occasionally (25%): Bending, climbing stairs, reaching overhead, carrying/pushing or pulling 1-10 pounds, grasping/squeezing.

Rarely (10%): Stooping/kneeling/crouching, lifting, carrying, pushing or pulling 11-15 pounds, operation of a motor vehicle.

Never (0%): Climbing ladder/step-stool, lifting/carrying/pushing or pulling 25-50 pounds, ability to hear whispered speech level.

Exposure to Elemental Factors

Never (0%): Heat, cold, wet/slippery area, noise, dust, vibration, chemical solution, uneven surface.

Blood-Borne Pathogen (BBP) Exposure Category

No Risk for Exposure to BBP

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