Utilization Review Specialist

Lexington Medical Center • West Columbia, SC

3d

About The Position

The Utilization Review Specialist performs admission and concurrent-stay medical record reviews to determine the appropriateness of admission, continued stay, and care setting. The specialist follows patients throughout hospitalization, collaborates with attending physicians and other health care providers, communicates with third-party payors to obtain authorization, contributes to appropriate patient throughput and length of stay, assists with denial management, and consults with physicians about the completeness of medical record documentation.

The role performs timely inpatient and Observation admission reviews using InterQual criteria and applicable Medicare and Medicaid regulatory guidelines. It submits clinical information to payors, records authorizations and review findings in the electronic medical record, conducts continued-stay reviews, supports accurate patient classification and billing, and refers cases without documented medical necessity to the Physician Advisor. The specialist also helps coordinate discharge planning, manages Medicare expedited discharge appeals, supports denial resolution, and serves as a resource and liaison for physicians, patients, families, and care teams on utilization and reimbursement matters.

This is a full-time, day-shift position with a stated schedule of 8:00 a.m. to 4:30 p.m. The position is in the Utilization Management Department at Lexington Health.

Requirements

• ADN, Diploma Nursing Degree, or Bachelor of Science in Nursing.
• At least 3 years of experience in an acute care hospital setting.
• Current Registered Nurse license in the State of South Carolina.
• Minimum education and experience are not substitutable.

Responsibilities

• Perform admission and continued-stay medical record reviews to assess medical necessity, appropriateness of care setting, and authorization needs.
• Review inpatient and Observation admissions promptly using InterQual criteria and applicable governmental guidelines for Medicare and Medicaid.
• Submit clinical information to third-party payors and document authorizations and pertinent clinical data in the electronic medical record and review worksheets.
• Conduct continued-stay reviews based on intensity of service, clinical response, expected length of stay, discharge readiness, and authorized-day intervals.
• Refer admissions lacking documented medical necessity to the Physician Advisor and follow through on the Advisor’s determination regarding level of care and billing.
• Certify Medicare admissions using established admission screening criteria.
• Apply appropriate condition codes and modifiers in the electronic medical record to support accurate claims information.
• Document denials and attempts to resolve or overturn them, and ensure payor communications are scanned for appeals.
• Consult with attending physicians when documentation does not support admission or continued stay, and seek complete clinical documentation.
• Serve as liaison between the Physician Advisor and attending physician and as a resource on patient classification and reimbursement.
• Issue non-coverage letters when an admission or continued stay is not certified, as necessary.
• Ensure patients and families are notified of Observation status and document the notification.
• Communicate insurance authorization information to physician offices as requested and reimbursement issues to the case management triad.
• Notify physicians and care team members about inappropriate admissions, denials, expiring authorized days, and other reimbursement-impacting issues.
• Participate in discharge planning and interdisciplinary patient care conferences; consult with the care team and support efficient discharge plans.
• Manage inpatient Medicare expedited discharge appeals through the QIO.
• Identify and document potentially avoidable days, abnormal utilization patterns, and opportunities for process improvement; refer concerns to management and recommend improvements.
• Assist Social Work staff with obtaining authorization for post-acute services as needed.
• Maintain effective working relationships and communicate with payors, physicians, patients and families, physician practices, internal departments, and external agencies.
• Maintain patient confidentiality and use discretion when handling protected health information.
• Follow appropriate channels to report progress and concerns, adapt to change, meet department and hospital goals, and perform other assigned duties, including emergency duties.
• Support a cooperative, respectful, service-oriented workplace; demonstrate role competence, teamwork, conflict resolution, telephone courtesy, and service recovery.
• Pursue professional development, completing at least 15 hours of continuing education related to the role annually.
• Serve as a role model and assist with staff orientation and training.

Benefits

• Medical, dental, and life insurance benefits effective day one.
• Health care and dependent care flexible spending accounts (FSAs).
• 403(b) matching plan eligible for enrollment on day one; employer matches dollar for dollar up to 6%.
• Employer-paid life insurance equal to one times salary.
• Optional supplemental life insurance with low-cost premiums up to three times salary.
• Employer-paid short-term and long-term disability coverage for full-time employees after 90 days of eligible employment.
• Adoption assistance.
• Tuition reimbursement.
• Student loan forgiveness.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree