RN CONTINUED STAY REVIEW SPECIALIST

Sparrow•Lansing, MI

1d•Onsite

About The Position

The Continued Stay Review Specialist performs utilization review using accepted screening criteria for medical necessity. This review includes appropriateness of health care services, utilization of hospital resources, and quality of patient care rendered at Sparrow Hospital. The role combines clinical, business and regulatory knowledge and skill to reduce significant financial risk and exposure caused by concurrent and retrospective denial of payment for services provided.

Requirements

Current Michigan Nursing License.
Minimum three (3) years of registered nurse experience in an acute care setting.
Graduate of an accredited nursing program
Ability to work independently and exercise sound judgement in interactions with physicians, payers, patients and their families.
Demonstrates ability to use a keyboard as may be required to perform the essential duties of the job.
Proficient with Microsoft Outlook, Excel, and Word with 80% passing score

Nice To Haves

Certification in Case Management (Preferred)
Experience in acute care case management, discharge planning, utilization review, performance improvement, and managed care reimbursement preferred
Bachelors degree in a healthcare related field preferred

Responsibilities

Assesses medical documentation for medical necessity using an established screening tool to determine the appropriate level of care for neonate, pediatric, adolescent, adult and geriatric patients.
Responsible to provide key clinical information to obtain authorizations from payers as needed.
Integrates knowledge of regulatory, business, and insurance requirements into determinations concerning admissions and length of stay.
Communicates with providers about medical screening results, and payer issues regarding patient classification.
Assists with the education of medical staff and other health care professionals regarding utilization of resources and regulations that impact the delivery of care, payer requirements, and patient classifications.
Coordinates an insurance physician peer to peer call when applicable.
Collaborates with physician advisors as necessary and identifies issues for escalation.
Learns and applies payer specific requirements and rules regarding utilization review.
Collaborates with the health care team regarding length of stay, treatment, and patient classification implications.
Verifies and documents the outcome of the utilization review, payer response, and physician interactions in the electronic record.
Demonstrates the ability to deliver and educate messaging letters to patients and patient representatives.