Overview

St. Luke's Health System in Boise is seeking an Utilization Reviewer to join our team.

In our efforts to improve health in the communities we serve, St. Luke's is excited to offer innovative orthopedic patient care at our state-of-the-art Center for Orthopedics & Sports Medicine facility (COSM). COSM will bring together numerous complementary healthcare services, such as orthopedic walk-in care, a surgery center, physical therapy, pharmacy services, and many more. Patients will experience accessible and affordable orthopedic care unlike any other in the Treasure Valley. Our 230,000-square-foot facility will open to patients in February 2024.

The Utilization Reviewer - RN is responsible for evaluating medical necessity for patient hospitalization and acting as an internal resource for patient care. Ensures that utilization functions are complying with hospital procedures and federal regulations.

Responsibilities

• Conducts timely clinical decision review for services requiring prior authorization in a variety of clinical areas, including but not limited to surgical procedures, Medicare Part B medications, Long Term Services and Supports, and Home Health.
• Reviews the medical necessity of admission, continued hospitalization, length of stay, and any potential denial of payment issues. Applies established criteria and employs clinical expertise to interpret clinical criteria to determine medical necessity of services. Performs Medicaid and Medicare review.
• Provides feedback and assistance to other members of the healthcare team regarding the appropriate use of resources and timely follow-through with the plan of care. Communicates results of reviews to the primary care team, specialty providers, vendors and members in adherence with regulatory and contractual requirements.
• Partners with physicians and other clinical departments to ensure appropriate cost-effective care. Facilitates escalated reviews in accordance with Standard Operating Procedures and in collaboration with clinical, medical staff and peer review teams. Handles complex utilization management related issues, seeks consultation when appropriate.
• Provides decision-making guidance to clinical teams on service planning. Ensures compliance with hospital, state, and federal regulations and requirements.
• Documents clinical decisions accurately and timely, working with utilization management leadership to ensure consistency in applying policy, as needed. Works with utilization management and clinical leadership teams to ensure policies, procedures, and regulatory and contractual requirements are met.
• Provides ongoing communication with health plan utilization departments regarding medical necessity for prospective, concurrent, and retrospective reviews. Collaborates with physicians related to appropriateness of admission and the prevention of denials. Intervenes when potential denials are determined and facilitates appeals when concurrent denials are received. Creates and maintains database of denied service requests.
• Maintains a broad knowledge of health care delivery that includes but is not limited to managed care regulations, contract terms/stipulations, utilization review and governmental agency regulations.
• Perform other duties and responsibilities as assigned.

Qualifications

QUALIFICATIONS: (Minimum qualifications required for the job)

• Education: BSN or ASN and two additional years of experience
• Experience: 3 years of RN or utilization management experience
• Licenses/Certifications: Current RN license in State of Practice

Why St. Luke's

A strong, talented staff is at the heart of St. Luke's Health System. We are the state's largest employer with more than 15,000 employees and a medical staff of more than 1,800 physicians and advanced practice providers. We're proud of our people who deliver skilled, compassionate care every day, and are looking to add dedicated individuals who will continue this same tradition of excellence.

*St. Luke's is an equal opportunity employer and does not discriminate against any person on the basis of race, religion, color, gender, gender identity, sexual orientation, age, national origin, disability, veteran status, or any other status or condition protected by law.