The Utilization Review Department provides many services to our multi-hospital organization including: Support to physicians and clinical staff in determining whether all aspects of a patient’s care, at every level is medically necessary and appropriately delivered. The Utilization Review department also acts to ensure compliance with the Medicare Conditions of Participation and capture of appropriate reimbursement for the health system.
Under the supervision of the Manager/Director, Utilization Review, the Utilization Management RN completes clinical reviews of hospital admissions for medical necessity, utilizing InterQual criteria, so that revenue is fully and accurately captured for hospital stays. Assures conformity to the federal and state government health care program requirements, the internal hospital utilization review process, and any third party payor utilization review processes or managed care process. Works closely with physicians, nursing staff, insurance companies, patient registration, and patient financial services to accurately document medical necessity and admitting status for each admission. This position does not directly manage any other caregivers.
ESSENTIAL FUNCTIONS AND DUTIES:
Performs clinical chart reviews for appropriateness and medical necessity of admissions, continued stays, and supportive services to promote quality care and full and accurate capture of revenue.
Following completion of clinical reviews for medical necessity of hospital stays, refers to second level review when necessary.
Communicates with the physicians, as needed to address issues of medical necessity and appropriate level of care -- and may provide support regarding Medicare documentation requirements. May obtain verbal admission orders from physicians and monitor for authorization by the physician. May participate in the delivery of regulatory forms to patients when appropriate.
Communicates with insurance companies regarding the medical necessity of the admission and provides clinical documentation and reviews to insurance companies as requested for purposes of ongoing authorization of hospital stays.
Keeps patient registration and patient financial services informed of any changes in admission status, working towards accurate capture of admission status prior to the time the initial billing is sent.
Continually assesses clinical services for appropriateness for continued stay.
Notifies case management of potential problematic cases.
Serves as a resource and actively provides education to physicians on inpatient and observation medical necessity criteria.
Participates with the Utilization Review Committee.
Quality of care issues are identified and reported through the EMS system or immediately if indicated, to risk management.
Has primary responsibility when medical necessity denials are received to complete an additional review and prepare and coordinate medical necessity appeals. Works closely with compliance auditor to provide clinical reviews and appeals for RAC, CERT, and MAC denials and audits.
Serves as a clinical resource for non-nursing members of the Utilization Management department.
Participates in clinical care conferencing.
Documents actions taken in the patient financial record and performs clinical reviews using commercial review criteria.
Participates in tracking of departmental quality measures by entering data in the UM database for compilation.
Supports the vision, mission and values of the organization in all respects.
Supports Value Improvement Practice (VIP- Lean) principles of continuous improvement with energy and enthusiasm, functioning as a champion of change.
Provides and maintains a safe environment for caregivers, patients and guests.
Conducts all activities with the highest standards of professionalism and confidentiality. Complies with all applicable laws, regulations, policies and procedures, supporting the organization’s corporate integrity efforts by acting in an ethical and appropriate manner, reporting known or suspected violation of applicable rules, and cooperating fully with all organizational investigations and proceedings.
Delivers customer service and/or patient care in a manner that promotes goodwill, is timely, efficient and accurate.
May perform additional duties of similar complexity within the organization, as required or assigned.