Access/Utilization Review Coordinator

Fisher-Titus Health•Norwalk, OH

4d•Onsite

About The Position

Under the general direction of the Supervisor, Utilization Review/Denials Management, collaborates with the medical staff, including the referring and admitting physicians, to ensure that hospital services and resources being requested are qualified based on regulatory and payer guidelines. Facilitates a patients’ entry into the hospital from all sources and into all entry points. Performs Medicare, Medicaid and all other payer requested reviews of patients who will be accessing or already utilizing hospital resources either as an inpatient or outpatient for Observation. Coordinates activities with Central Scheduling to obtain clinical authorization.

Requirements

Collaborates with the medical staff, including the referring and admitting physicians, to ensure that hospital services and resources being requested are qualified based on regulatory and payer guidelines.
Facilitates a patients’ entry into the hospital from all sources and into all entry points.
Performs Medicare, Medicaid and all other payer requested reviews of patients who will be accessing or already utilizing hospital resources either as an inpatient or outpatient for Observation.
Coordinates activities with Central Scheduling to obtain clinical authorization.
Accurately applies nationally recognized acute care and transition criteria to determine qualifications for hospital level of care.
Assists the physician in determining if a patient is qualified for hospital level of care or continued stay.
Reviews all cases regardless of access entry point, including: emergency department, direct admissions, transfers from other facilities, ambulatory and outpatient services.
Assesses patient’s severity of illness and intensity of services (SI/IS), collaborates with the admitting physician to assign a level of care.
Identifies cases where SI/IS criteria are not met; uses initiative and good judgment when referring the case to the case manager, medical advisor or attending physician for further review.
Informs if hospital services being considered are non-qualified for inpatient acute level of care or outpatient observation services.
Maintains knowledge of and adheres to review policies and processes as defined within the Fisher Titus Medical Center Utilization Review/Audit Plan.
Uses the appropriate screening tool per Fisher-Titus Medical Center Utilization Review plan and per Fisher Titus Medical Center Policy and process.
Utilizes available software to record chart review findings and submits the information to the appropriate payer.

Responsibilities

Stays current on regulations and guidelines affecting hospital level of care eligibility and accurately applies nationally recognized acute care and transition criteria to determine qualifications for hospital level of care.
Uses objective criteria, as defined by the Fisher Titus Medical Center Utilization Management Plan, to assist the physician in determining if a patient is qualified for hospital level of care or continued stay.
Reviews all cases regardless of access entry point, including: emergency department, direct admissions, transfers from other facilities, ambulatory and outpatient services.
Based on available documentation within the medical record, assesses patient’s severity of illness and intensity of services (SI/IS), collaborates with the admitting physician to assign a level of care.
Demonstrates the ability to identify cases where SI/IS criteria are not met; uses initiative and good judgment when referring the case to the case manager, medical advisor or attending physician for further review.
Promotes the use of evidence-based protocols and guidelines.
Discusses cases with admitting physician, medical advisor, and/or case manager to inform if hospital services being considered are non-qualified for inpatient acute level of care or outpatient observation services.
Maintains knowledge of and adheres to review policies and processes as defined within the Fisher Titus Medical Center Utilization Review/Audit Plan.
Uses the appropriate screening tool per Fisher-Titus Medical Center Utilization Review plan and per Fisher Titus Medical Center Policy and process.
Utilizes available software to record chart review findings and submits the information to the appropriate payer.