Utilization Review Specialist

CASS REGIONAL MEDICAL CENTER•Harrisonville, MO

7d•Onsite

About The Position

Primary Purpose: To review patient records to determine the medical necessity of admission, treatment, and length of stay at Cass Regional Medical Center in order to maintain compliance with government and insurance reimbursement policies. Assists with admission management for all admissions. Performs other duties as assigned.

Requirements

Knowledge of insurance guidelines, admission criteria regulations, federal, state, and joint commission regulations as well as hospital policies and procedures and knowledge of medical terminology.
Strong communication skills; ability to work independently; proficient at computer use.
Two (2) or four (4) year RN degree required.
MO or Compact RN license with 2 years of Med Surg bedside nursing required.

Nice To Haves

BSN preferred.
Working knowledge/experience in utilization review management, managed care and payer issues preferred.
MCG certificate recommended after 1 year of acceptance.

Responsibilities

Works in collaboration with providers and other healthcare personnel in patient evaluation and treatment.
Communicates with providers as appropriate regarding daily patient care and coordination.
Completes and maintains case management within electronic health record on each scheduled work day, utilizing the MCG Indicia model interface with Meditech.
Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency.
Supports department based goals which contribute to the success of the organization; serves as a preceptor, mentor and resource to less experienced staff.
Serves as a resource for admission criteria guidelines.
Utilizing the ‘AIDET’ (Acknowledge, Introduction, Duration, Explain, Thank) model, conducts an appropriate introduction, reviews the plan of care, mutually sets attainable patient goals.
Performs insurance pre-certifications and appeals daily on a case by case basis.
Performs admissions, concurrent focused reviews and inpatient certifications on each scheduled workday.
Serves as a resource person and provides counseling and intervention related to treatment and disposition.
Assists with the appeals process for insurance denials daily on a case by case basis.
Maintains hospital guidelines for release of records and patient confidentiality daily.
Assists case management manager with yearly review and revisions of utilization review policy and procedure manuals to maintain compliance.