Utilization Review Analyst

Franciscan Sisters of Christian Charity Sponsored Ministries Inc•West Point, NE

7d•Onsite

About The Position

Franciscan Healthcare is looking for a Utilization Review/Concurrent Analyst to perform case reviews, check medical records, speak with patients and care providers regarding treatment, and respond to the plan of care. You will also make recommendations regarding the appropriateness of care for identified diagnoses based on the research results for those conditions.

Requirements

RN / LPN preferred or Utilization Management background.
Knowledge of ICD-10-CM and ICD-10-PCS coding system, or willingness to learn.
Knowledge of current CPT coding principles and guidelines, or willingness to learn.
Knowledge of Medicare/Medicaid/Insurance regulations; or willing to learn.
Ability to maintain strict confidentiality in all hospital/patient related matters.
Excellent written and oral communication skills including the English language.
Computer skills necessary, experience with Electronic Health Record.
Ability to pay close attention to detail.
Ability to communicate effectively with physicians, outside insurance reviewers, clinic personnel, nursing home personnel, patient’s and patient families as well as other hospital departments.
Ability to accept change in regard to policy/procedure; CMS/insurance rules/regulations, frequently and at times with little or even retrospective notice.

Responsibilities

Complete daily/concurrent Utilization Management reviews of all current Inpatients, Swing Bed patients, Outpatient Observation patients, Outpatient and Ambulatory Surgery patients using Milliman Care Guidelines and Cerner EHR, on a rotation schedule with other Utilization Review/Management personnel.
Insurance authorization for the patient’s specific setting
Follow-up reviews as required/requested by the individual insurance group
Appropriateness of the assigned hospital setting
Review for documentation requirements by medical staff
Assignment of working DRG on admission
Assignment of appropriate MCG guideline criteria based on admission information
Monitor and complete initial and follow-up IMM for Medicare, Medicare Advantage and TRICARE inpatients
Complete appropriate notices as applicable for patient’s hospital stay per UM Policy and Procedures
Monitor the 2-midnight rule for Medicare patients in the Outpatient Observation setting and advise physicians regarding appropriateness of admission and documentation
Responsible for remaining up-to-date and knowledgeable of regulations and remain current about federal legislative changes that affect patient outcomes.
Work closely with all hospital departments to assure accuracy in patient’s encounter.
Work with physicians, PA’s and NP’s to resolve issues/questions and documentation to assure accurate claim submission.