UR Specialist

Cincinnati Children's

1d•$69,389 - $88,608•Remote

About The Position

The UR Specialist performs admission and continued stay reviews on patients to determine the medical necessity of severity of illness and intensity of service for certification of admission and continued stay using approved medical management criteria tools like Interqual. This role involves recording all required documentation, maintaining pertinent statistical data, and interfacing with various departments (Admitting, Financial Counseling, Health-care team) to ensure accurate insurance information, coordination of benefits, and proper documentation for patient stays. The specialist also communicates with third-party payers to certify inpatient stays and identifies potential issues that could delay discharge. Additionally, the UR Specialist works to overturn potential denials, assists with retrospective reviews, and collaborates with Revenue Management Cycle members for reimbursement. A key aspect of the role involves ensuring compliance with JCAHO, Medicaid, Medicare, and other third-party payer standards, staying knowledgeable about regulatory changes, and reporting on utilization metrics. The position also serves as an educational resource to various stakeholders regarding utilization review activities.

Requirements

Bachelor's degree in a related field
2+ years of work experience in a related job discipline
Current, unrestricted Registered Nurse (RN), Social Work or Clinical Counselor Licensure in the state(s) of practice

Nice To Haves

Experience with Payers - (Commercial and Government)

Responsibilities

Perform admission and continued stay reviews on patients to determine the medical necessity of severity of illness and intensity of service for certification of admission and continued stay utilizing approved medical management criteria tools.
Record all required documentation on patient review forms and in computerized systems to maintain a record of the review and the coverage obtained for a patient.
Maintain pertinent statistical data as required by the department.
Interface with the Admitting Department and/or the Financial Counseling departments to identify correct insurance, coordination of benefits information, effective dates of coverage, pre/admission notifications/authorizations for certification of inpatient admissions.
Interface with other members of the health-care team regarding the implementation of discharge planning and the certification justification documentation of patient stays, advising them of external/third party requirements and criteria.
Communicate with third party payers to certify inpatient stays.
Using data extrapolated from electronic systems, attempt to recognize issues that potentially cause a delay in discharge.
Works closely with respective parties within the organization to facilitate interaction between medical center personnel and payer personnel to overturn potential and/or final denials.
Assists with the retrospective review of records for patients who have insurance changes that impact the authorization of the inpatient encounter.
Works with identified Revenue Management Cycle members to obtain reimbursement through the revised/new certification of patient stays.
Reviews timeliness, accuracy and security of new information.
Assist Director in meeting current JCAHO, Medicaid, Medicare, and other third-party payer standards and requirements.
Maintains knowledge of changes as impacts regulatory/accrediting compliance for reimbursement.
Assist Director in the reporting of information as set forth in the PI plan, i.e., appropriateness of admissions and continued stay reviews including when known, the over and under utilization of resources.
Participate in payer, Revenue Management Cycle and interdepartmental meetings to promote knowledge, troubleshoot, problem shoot and resolve issues as relates to utilization management.
Serves as an educational and communications resource to Administration, Department heads, physicians and other necessary groups regarding the utilization review/management activity and process.
Keep the department manager informed of problems as necessary.
Serves as an educational and communications resource to Administration, Department heads, physicians, and other necessary groups regarding Utilization Review.