RN - Utilization Management / Clinical Denial Management

Carle Health•Peoria, IL

2d•$36 - $58•Onsite

About The Position

As a member of the Utilization Management team, provides concurrent and retrospective clinical review of inpatient/observation medical records to evaluate the utilization of acute care services. The goal of concurrent review includes facilitation of appropriate physician documentation that accurately reflects the patient's severity of illness and intensity of service. Team members will also provide payers with requested information regarding the patient stay in a timely manner, to facilitate payment for services rendered.

Requirements

College Diploma: Nursing
Licensed Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR)
Licensed Practical Nurse (LPN) - Illinois Department of Financial and Professional Regulation (IDFPR)
Use of usual and customary equipment used to perform essential functions of the position. Upon Hire
Writes, reads, comprehends, and speaks fluent English
Microsoft Office Computer knowledge skills
Multicultural sensitivity
Possesses courteous and effective telephone etiquette
Possesses ability to prioritize and maintain organization.
Strong communication skills.
Work Experience: Acute care.

Responsibilities

Demonstrates sound knowledge of Interqual criteria when conducting chart reviews.
Utilize CERME to perform medical necessity reviews
Conduct Admission, Observation follow up, and Continued Stay reviews, identifying cases that documentation does not support severity of illness or intensity of service, thereby failing to meet criteria for admission.
Refer cases to Secondary Medical Review, when appropriate, for assistance in determination of proper admission status, Observation follow up, or Continued Stay status.
Demonstrates ability to document proper order status in electronic health record.
Demonstrate the ability to place a status order, at the direction of the provider, into the electronic health record.
Demonstrate proficiency in the Medicaid review process, as well as the eQHealth system.
Demonstrate knowledge of the IPO surgery list.
Demonstrate the ability to communicate review finding with Case Management, Social Services, Providers, or other ancillary departments as part of the continuum of care for the patient.
Provide concurrent clinical review to UR agencies and communicates discharge plan as indicated.
Discuss concerns, comments, length of stay, or coverage concerns from UR agencies or insurance providers, with Case Management, Social Services, or providers, or other ancillary departments as appropriate.
Provide clinical updates or requests for information to UR agencies or insurance providers in a timely manner.
Demonstrates proper documentation of communication with UR agencies and insurance payers, physicians, Case Management, Social Services, or other Ancillary Departments, into the patient’s Electronic Health Record. This pertains to communication received from such as well as communication to said parties.
Participates in Utilization Management process for retro reviews, denials, P2P notifications to providers and follow up, and appeals.
Utilizes E.HR as applicable to assist in denial management as requested.
Complete follow up calls to UR agencies and insurance providers for certification of days as necessary.
Act as a resource to ED/Surgery staff on weekends, in reviewing intensity of service, severity of illness, and documentation to support admission status when requested.
Act as a resource, when requested, to those who may need Utilization Management support or assistance, in providing for the continuum of care for the patient.
Creates a welcoming environment for the person’s served. Effectively manages positive relationships with staff, physicians, ancillary staff, and third party payers.
Monitors and completes accounts on multiple work queues in electronic medical record.
Monitors requests in work queue for clinical information. Prepares/faxes documents for review, to third party payers. Ensures receipt of documents. Documents sending of clinical information in patient chart.
Monitor/document third party payers approved days, denials, requests for further information.
Communicate opportunities for Peer to Peer from third party payers, with our physicians (at Methodist/Proctor/Pekin). Document requests/results of Peer to Peer conversations in patients electronic health record.
Other duties as assigned, to meet the day to day operational needs of Utilization Management.