Utilization Review Specialist

Cincinnati Children's•Andrews, IN

About The Position

JOB RESPONSIBILITIES Case Management- 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. This is done utilizing the approved medical management criteria tool i.e. Interqual. 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. Communicates 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 i.e. poor documentation of SI/IS, delay days and the cause thereof etc. Authorization Process- 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. Compliance- 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. Training & Education- Serves as an educational and communications resource to Administration, Department heads, physicians, and other necessary groups regarding Utilization Review.

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

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.
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.
Communicates 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 i.e. poor documentation of SI/IS, delay days and the cause thereof etc.
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.