Branch Review Specialist jobs in Nevada

The UR Specialist reviews and monitors patients’ utilization of health care services with the goal of maintaining high quality, cost-effective care. The duties include providing the medical and utilization expertise necessary to evaluate the appropriateness and efficiency of medical services and procedures.

• Performs concurrent and retrospective reviews on all patients. Monitors level and quality of care.
• Responsible for the proactive management of patients with the objective of improving quality outcomes and decreasing costs.
• Evaluates and provides feedback to treating physicians regarding a patient’s discharge plans and available covered services, including identifying alternative levels of care that may be covered.
• Monitors all utilization reports to assure compliance with reporting and turnaround times.
• Addresses care issues with the Director of Clinical Services and Chief Medical Officer/Medical Director as appropriate.
• Coordinates an interdisciplinary approach to support continuity of care.
• Provides utilization management, transfer coordination, discharge planning, and issuance of all appropriate authorization for covered services as needed.
• Identifies and recommends opportunities for cost savings and improving the quality of care across the continuum.
• Clarifies health plan medical benefits, policies and procedures for members, physicians, staff, contract providers, and outside agencies.