Utilization Review Specialist
West River Health Services·Hettinger, North Dakota
West River Health Services·Hettinger, North Dakota
The Utilization Review Specialist monitors resource utilization and quality of care for patients, ensuring compliance with established guidelines. They perform preadmission reviews, coordinate with discharge planners, and manage insurance communications.
Under the direct supervision of the HIM manager, the UR specialist monitors the utilization of resources, risk management and quality of care for patients in accordance to established guidelines and criteria for designated setting and status. Collection of clinical information necessary to initiate commercial payer authorization. Obtain and maintain appropriate documentation concerning services in accordance to reimbursement agency guidelines.
Performs preadmission review on admissions when required by insurance companies/agencies to comply with policies and procedures.
Works in coordination with discharge planner, monitoring medical necessity for admissions and appropriate level of services.
May also need to notify physician and patient of authorization denials.
Inputs collected data into computer system for insurance communication.
Assists with retrospective review of specified charts as required.
Obtains extensions in length of stays from insurance companies if needed.
Obtains preauthorization and/or precertification of services.
Reviews hospital records daily to determine if utilization resources could be served in a better environment, OBS vs INPT.
Ability to interact on an interpersonal basis with providers and other staff within the organization.
Market context
Pulmonary, critical care, and sleep physician roles in North Dakota are typically shaped by steady demand for specialists who can cover complex inpatient and outpatient needs across a broad geographic area. These positions are competitive because employers often look for board eligibility or certification, state licensure in North Dakota and/or Minnesota, and the ability to meet certification timelines after hire. Review the AI-summarized requirements and benefits here to quickly compare fit, then confirm licensure and board status before applying.
