Utilization Management Review Analyst - NICU

Woman's Hospital Foundation • Baton Rouge, LA

58d • $30 - $48 • Onsite

About The Position

The Utilization Management Review Analyst analyzes patient records daily to determine the appropriateness of admission, level of care, continued stay and discharge. Abstracts variances to standard pathway process and provides ongoing support and expertise through comprehensive assessment, planning, implementation and overall evaluation of individual patient needs. Works directly with physicians, insurance companies, HIM supervisors, nursing staff, Infection Control staff, managed care, case management, Patient Accounting and Patient Services. Exercises concurrent review techniques utilizing evidence-based guidelines such as Interqual and Milliman to communicate with multidisciplinary personnel and insurance providers; Enhances the quality of patient management and satisfaction while promoting continuity of care and cost effectiveness through integration of utilization management, case management and discharge planning. Performs various duties assigned by department management according to policies and procedures and the mission of Woman's Hospital.

Requirements

• Graduate of an accredited school of nursing; currently licensed to practice professional nursing in the State of Louisiana.
• Must have a minimum of two years' prior experience in a hospital setting, such as maternal and infant health, perinatal behavioral health, or med-surg/oncology.
• 3-5 years' experience in Case Management/Utilization Review is required.

Nice To Haves

• BSN strongly preferred.

Responsibilities

• Performs admission screening within 24 hours of admit for inpatient and outpatient based on criteria and standards approved by the medical staff in accordance with applicable accreditation, regulatory, and third-party payor requirements.
• Reviews Medicare, Medicare Advantage, and CHAMPUS admissions within 24 hours of admit for medical necessity and appropriateness of admission.
• Provides data to managed care companies on patients for initial and continued stay necessity within 24 hours of receipt of call.
• Appeals denials as necessary providing supporting documentation to managed care companies. Sets up physician to physician appeals as necessary. Notifies managed care department of denials and status of appeal.
• Reviews Medicare, Medicare Advantage, and CHAMPUS patients for medical necessity for continued stay review utilizing generic and/or body system discharge screening criteria. Notifies Social Services for discharge planning. Provides CHAMPUS with clinical data for continued stay.
• Performs periodic medical record review using review table for elements of medical record standards. Submits these reviews to the Medical Review Analyst by the designated date.
• Maintains an up-to-date knowledge based on a wide spectrum of clinical conditions, procedures and diseases in the areas of OB/GYN, neonatology, oncology and adult and neonate critical care. Articulates on these subjects to substantiate medical necessity when providing clinical information to nurse reviewers at insurance companies.
• Reviews discharge list on a daily basis, verifies that all dates are certified and calls insurance companies to verify discharge dates as required.
• Assists in special projects, data collection, maintains databases and prepares/presents reports as assigned.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Hospitals
• Number of Employees: 1,001-5,000 employees