CAREER GUIDE FOR UTILIZATION REVIEW ANALYST

SOC Code: 29-9099

Pay Band(s): 4 and 5    (Salary Structure)

Standard Occupational Description: There is no standard occupational description for the occupation of Utilization Review Analyst as used by the Commonwealth. This occupation would be included in the Healthcare Practitioners and Technical Workers, All Others. This group is comprised of many different types of healthcare practitioners' occupations with a wide range of characteristics. 

Commonwealth of Virginia Description: Analyze patient records to determine legitimacy of admission, treatment, and stay in health-care facility and community based entities to comply with government and insurance companies reimbursement policies.

Utilization Review Analyst positions in the Commonwealth are assigned to the following Roles in the Healthcare Compliance Career Group:

Health Care Compliance Specialist I

Health Care Compliance Specialist II

While Utilization Review Analysts within the Commonwealth are all located within the Healthcare Compliance Career Group, individuals may want to pursue other opportunities within the Commonwealth depending upon individual training, education, knowledge, skills, abilities, and interests.   

Other Career Group(s) that may be of interest are:

Nursing/Physician Assistance Services

Physician Services

Counseling Services

Program Administration

SKILLS, KNOWLEDGE, ABILITIES AND TASKS

(Technical and Functional Expertise)

Skills
Note: The technical and functional skills listed below are based on general occupational qualifications for Utilization Review Analysts commonly recognized by most employers.  Typically, you will not be required to have all of the skills listed to be a successful performer.  Recruitment and selection standards for an individual state job must be based on the specific knowledge, skills, and abilities for that job as indicated in the job announcement and job description in the Employee Work Profile.

1. Considering the relative costs and benefits of potential actions to choose the most appropriate one.
2. Understanding written sentences and paragraphs in work related documents.
3. Giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times.
4. Communicating effectively in orally and in writing as appropriate for the needs of the audience.
5. Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems.
6. Using mathematics to solve problems relating to health care payments.
7. Identifying measures or indicators of system performance and the actions needed to improve or correct performance, relative to the goals of the system.
8. Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions.
9. Using scientific rules and methods to solve problems relating to health and medical services rendered.
10. Managing a caseload for reviewing and evaluating information provided by providers to obtain authorization of payment.

Knowledge
Note: The technical and functional knowledge statements listed below are based on general occupational qualifications for Utilization Review Analysts commonly recognized by most employers.  Typically, you will not be required to have all of the knowledge listed to be a successful performer.  Recruitment and selection standards for an individual state job must be based on the specific knowledge, skills, and abilities for that job as indicated in the job announcement and job description in the Employee Work Profile.

The Knowledge of:

1. Medical and surgical techniques needed to diagnose and treat various medical conditions such as injuries and disabilities. This includes practices and standards of care, symptoms, treatment alternatives, medications used for treatment and preventive health-care measures.
2. Health care needs of the disabled and elderly and community resources.
3. Medical Terminology and research techniques.
4. Information technology and use of computer related software such as Windows and Word.
5. Human behavior and performance; individual differences in ability, personality, and interests; learning and motivation; psychological research methods; and the assessment and treatment of behavioral and affective disorders.
6. Principles, practices and professional standards of medical records management, practice procedures and terminology.
7. Laws, legal codes, court procedures, precedents, government regulations, executive orders, agency rules, and the effect on financing in relation to the utilization process.
8. Payment practices and the analysis and reporting of financial data.
9. Relevant equipment, policies, procedures, and strategies to promote effective local, state, or national security operations for the protection of people, data, property, and institutions.
10. Structure and content of the English language including the meaning and spelling of words, rules of composition, and grammar.

Abilities
Note: The technical and functional abilities listed below are based on general occupational qualifications for Utilization Review Analysts commonly recognized by most employers.  Typically, you will not be required to have all of the abilities listed to be a successful performer.  Recruitment and selection standards for an individual state job must be based on the specific knowledge, skills, and abilities for that job as indicated in the job announcement and job description in the Employee Work Profile.

The Ability to:

1. Read and understand information and ideas presented in writing.
2.  Listen to and understand information and ideas presented through spoken words and sentences.
3. Communicate information and ideas in speaking so others will understand.
4. Communicate information and ideas in writing so others will understand.
5. Combine pieces of information to form general rules or conclusions (includes finding a relationship among seemingly unrelated events).
6. Add, subtract, multiply, or divide quickly and correctly.
7. Apply general rules to specific problems to produce answers that make sense.
8. Choose the right mathematical methods or formulas to solve a problem.
9. Tell when something is wrong or is likely to go wrong. It does not involve solving the problem, only recognizing there is a problem.
10. Research and identify changes in requirements and policies and to interpret regulations.

Tasks
Note:  The following is a list of sample tasks typically performed by Utilization Review Analysts.  Employees in this occupation will not necessarily perform all of the tasks listed. 

1. Conduct utilization review studies and review applications and process pre-authorizations for health care services.
2. Manage assigned cases through problem solving, education and referral.
3. Analyze insurance, governmental, and accrediting standards to determine criteria concerning admissions, treatment and length of patient stay.
4. Confer with medical, nursing personnel and other professional to determine legitimacy of treatment and length of stay.
5. Act as a resource for providers, staff and others on regulations, policies and procedures and the utilization plan.
6. Assure compliance with state and federal regulations and billing requirements.
7. Ensure high standard of client care by establishing best practice benchmarks.
8. Identify patterns of over-utilization and abusive or fraudulent practices.
9. Maintain statistical records and provide statistical data to management.
10. Conduct quality management related training for others.
11. Identify, examine, and resolve cases of fraud, abuse, or misutilization or refer to a fraud unit for investigation.

INTERESTED?

Like people, occupations have traits or characteristics.  These characteristics give important clues about the nature of the work and work environment, and give you an opportunity to match your own personal interests to a specific occupation.  When you choose a job in an occupation that matches your own interests you have taken an important step in planning a successful and rewarding career.

The occupation of Utilization Review Analyst has characteristics as described below:

Investigative — Investigative occupations frequently involve working with ideas, and require an extensive amount of thinking. These occupations can involve searching for facts and figuring out problems mentally.

Social — Social occupations frequently involve working with, communicating with, and teaching people. These occupations often involve helping or providing service to others.

Conventional — Conventional occupations frequently involve following set procedures and routines. These occupations can include working with data and details more than with ideas. Usually there is a clear line of authority to follow.

LICENSURE, REGISTRATION, OR CERTIFICATION REQUIREMENTS

Generally licensure is required for Utilization Review Analyst positions in state government. 

Depending on the area of review, the utilization review analyst may be a registered nurse, licensed clinical social worker, licensed clinical psychologist, physician, or other health professional. Whatever health profession is required; the licensure requirements for that profession must be met.

Licensing information for health care professionals can be found on the Department of Health Professional's web site at http://www.dhp.state.virginia.us/.

A valid driver's license is required.

EDUCATIONAL, TRAINING, AND LEARNING OPPORTUNITIES 

The Agency for Health Care Administration provides the following information:

The purpose of the utilization review program is to safeguard against unnecessary and inappropriate medical care rendered to Medicaid recipients. Medical services and/or records are reviewed for medical necessity, quality of care, appropriateness of place of service and length of stay (inpatient hospital).

There are many types of health-care facilities' services that are reviewed such as inpatient hospital, home health, community mental health, and home and community based waiver services. The type of health-care facility being reviewed dictates the educational requirements for the analyst who conducts the review. For example, a utilization review of a community mental health facility typically requires the analyst to have major coursework in psychology, counseling, social work or a related field. Graduation from an accredited school with a bachelor's or master's degree in psychology, clinical social work or related field is the educational requirements for analysts conducting reviews of community mental health services.

However registered nurses are typically sought for job openings in utilization review. Educational preparation to become a registered nurse is offered in three different types of programs in the Commonwealth.  They are four-year college programs offering bachelor's degree, community colleges offering associate degrees and hospital-based schools offering diplomas. Most employers prefer a baccalaureate degree with clinical work experience in the related utilization review area.

The State Council of Higher Education lists many Virginia educational institutions offering programs in nursing and other medical and heath professions on their web site: http://research.schev.edu/degreeinventory/inventory_

COMMONWEALTH COMPETENCIES

Competencies are a set of identified behaviors, knowledge, skills, and abilities that directly and positively impact the success of employees and the organization. Competencies can be observed and measured.  When consistently demonstrated, competencies make employees particularly effective in their work.  Competencies help lay out a road map to career success.  You can use the Commonwealth Competencies to help improve your individual performance by adopting behaviors that make high performing employees successful in their jobs. In this way, you can use the Commonwealth Competencies for your further professional development.

The Commonwealth Competencies are:

1. Technical and Functional Expertise
2. Understanding the Business     
3. Achieving Results
4. Serving the Customer
5. Teamwork
6. Interpersonal and Communication Skills
7. Leadership and Personal Effectiveness

The above competencies may be applied to employees throughout the Commonwealth of Virginia.  They can be rank-ordered by agencies and hiring managers to represent the needs of a specific job.  The rank ordering will change depending upon the occupation, an organization's priorities, the actual job requirements, and the supervisor's preferences. 

Career success is both about what you do (applying your technical knowledge, skills, and ability) and how you do it (the consistent behaviors you demonstrate and choose to use) while interacting and communicating with others.  Hopefully, by studying the Commonwealth competencies, identifying your developmental opportunities, and working to refine your own competence, you can take charge of your career!

For additional information about the Commonwealth Competencies go to: http://jobs.virginia.gov/cc_planningctr.htm.  For the competencies, we first list the competencies and then define each.  Finally, we list competency indicators; to describe what successful performance looks like. 

COMMONWEALTH CAREER PATH

Career opportunities in the Commonwealth are not limited to moving “up” to the next highest role and pay band, changing positions, or to becoming a supervisor.  That's because most roles describe a broad group of occupationally related positions that perform a range of work that requires increased knowledge and skills.  For that reason, Commonwealth roles describe the career paths within the same or higher-level role for the same or different Career Group.  The broad salary range and the Commonwealth's pay practices provide flexibility in recognizing career development and advancement. (Salary Structure)

For example: Utilization Review Analyst

Sample Career Path

Health Care Compliance Specialist I

The Health Care Compliance Specialist I role provides career tracks for compliance specialists performing responsibilities ranging from entry level professional to first line supervisor. Employees audit, investigate, and inspect records, public and private operations, or facilities, to identify discrepancies in eligibility determinations, payment and billing calculations for individuals, third-party providers, or case records.

Health Care Compliance Specialist II

The Health Care Compliance Specialist II role provides career tracks for compliance specialists that either: plan and administer all aspects of a quality assurance, health care compliance, and utilization review programs; or are licensed health care professionals conducting inspections of service delivery and service providers.

Health Care Compliance Manager

The Health Care Compliance Manager role provides career tracks for managers who manage and direct quality assurance, health care compliance, and utilization review program operations. The work includes development, implementation, and evaluation of operational goals, objectives, policies, procedures, legislative recommendations, and operating budget.

ADDITIONAL OCCUPATIONAL INFORMATION CAN BE FOUND AT: 

O*NET (Occupational Information Network) 

http://online.onetcenter.org/gen_search_page

Virginia Employment Commission 

http://www.alex.vec.state.va.us/

Career One Stop

  http://www.careeronestop.org/

Virginia Career Resource Network

 http://www.vacrn.net/