The Utilization Review Specialist uses medical necessity guidelines to determine appropriateness for inpatient level of care or observation services based on documented clinical information including symptoms, findings, treatment plan and admitting orders to ensure compliance with CMS guidelines and other payer requirements regarding appropriate level of care.Possesses in-depth knowledge and ability to apply various payer rules and regulations, admission, discharge and continued stay criteria, and InterQual and/or MCG guidelines. Documents reviews and communicates information to payers in accordance with contractual obligations. Establishes and maintains effective professional working relationships with physicians, interdisciplinary team members, registration, financial counseling, patient billing, HIM, CDI, payers and external case managers. Uses time effectively, plans and prioritizes daily workload while maintaining flexibility to meet health system need. Confers with physician when documentation of the patient’s condition and plan do not meet acute care criteria and arranges peer-to-peer as indicated to prevent denials. Consults with physician advisor as necessary to review and resolve level of care concerns through appropriate discussion with the physician and administrative channels as needed. Communicates with the assigned Case Manager when denial is upheld for expedited discharge. Identifies quality of care issues and escalates though chain of command for action. Identifies and records avoidable days. Brings unresolved cases to Team Leader/System Manager for consultation and guidance. Identifies when to utilize Medicare condition code 44 process. Participates in data collection and analysis; provides recommendations for promotion of quality, cost-effective outcomes. Keeps current with all regulatory changes that affect delivery or reimbursement of acute care services including HIPPA, Patient Bill of Rights, EMTALA, Medicare Outpatient Observation Notice (MOON) and Hospital Initiated Notice of Non-Coverage (HINN). Provides education and updates about utilization management and regulatory changes. Serves as staff support to Utilization Management Committee as requested.
RN with at least two (2) years of clinical experience in an acute care setting.
BLS is required for any RN, LPN, PCT, Patient Transporter or other direct patient care provider. Emergency Department, Intensive Care Units, PACU, Medical Emergency Team and Anesthesia require ACLS. Pediatrics, SICU, Emergency Department and Medical Emergency Team also require PALS.