Utilization Review Specialist
Cleveland, OH (on-site)
$40-45/HR
8:30 am-5 pm (M-F)
The UR Specialist plays a critical role in coordinating resident assessments, care planning, utilization review, reimbursement, and interdisciplinary communication to ensure high-quality, cost-effective resident care while maintaining compliance with state and federal regulations.
UR Specialist Responsibilities:
- Coordinate and oversee completion of MDS 3.0 assessments and comprehensive resident care plans.
- Complete assessments for newly admitted residents and residents experiencing significant changes in condition.
- Review interdisciplinary documentation to ensure accurate and complete resident assessments.
- Maintain compliance with CMS, Medicare, Medicaid, State of Ohio, and federal documentation requirements.
- Attend utilization review meetings and collaborate with interdisciplinary teams regarding resident eligibility and insurance coverage.
- Monitor Medicare and managed care benefits, including tracking Medicare benefit days.
- Promote resident rights, dignity, privacy, and confidentiality.
UR Specialist Qualifications:
- Current, valid, and unrestricted LPN or RN license in OH is preferred but not required.
- Previous MDS coordination and utilization review experience in a skilled nursing or long-term care setting.
- Experience with managed care authorization processes.
- Strong clinical assessment skills.
- Flexibility to work occasional evenings, weekends, or additional hours as needed.
- Knowledge of:
- Medicare
- Medicaid
- PPS reimbursement
- Subacute/skilled nursing care
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