Utilization Review Coordinator RN

MyMichigan Health•Saginaw, MI

20h

About The Position

This position plays a pivotal role in maintaining the fiscal health of the organization by ensuring the organization is fully reimbursed. Educating and consulting with the physician and the health care team to ensure accuracy of medical necessity criteria and to ensure timely and appropriate level of care is achieved. This requires excellent time management and prioritization skills along with collaboration with the provider and case management teams.

Requirements

Credential:RN: Registered Nurse
Education: Associates Degree
Three to five years clinical experience.

Nice To Haves

Prior UR experience and/or certification in U/R or Case Management preferred. Basic knowledge of coding preferred.

Responsibilities

(30%) Performs admission, concurrent and focused reviews using the medical necessity criteria and complies with CMS requirements. Perform admission/continued stay/discharge reviews when applicable.
(30%) Determines necessity of second-level review and implement process per hospital policy. Provide educational information to physicians and other staff members as appropriate regarding medical necessity criteria, documentation guidelines, admission status, etc. and collaborates with the care team.
(15%) Assist UR Committee and subcommittees in identifying areas of mis-utilization. Perform Hospital- wide quality assurance activities as requested.
(15%) Facilitate appropriate insurance pre-certification, appropriate admission and status of patient. Successfully negotiates patient status with the payer.
(10%) Attend and participate in case management and discharge planning as required.
Complete denial appeals with physician and additional chart information, coordinate information and send in appeal. Coordinate with Appeals RN, as needed.
Maintain documentation of reviews, telephone contacts, appeal activity and progress.
Provides pertinent clinical data to designated outside agencies to assure compliance with their requirements.
Participates in Continuous Quality Improvement as required by the Medical Center and the job description.
Is skilled in determining the need for and implementing the hospital notice of non coverage.
Understands and is accountable for the Health System's customer service standards.