Utilization Review Specialist RN PRN

Job Summary

Performs admission and concurrent stay medical record review to determine appropriateness of admission, continued stay, and setting. Follows patient throughout hospitalization collaborating with attending physician and other health care providers. Communicates with third party payors to obtain authorization. Contributes to appropriate throughput and length of stay. Assists with denial management.

Minimum Qualifications

• Minimum Education: ADN, Diploma Nursing Degree, or Bachelor of Science in Nursing
• Minimum Years of Experience: 3 Years of experience in an acute care hospital setting

Essential Functions

• Works in a cooperative manner, which fosters favorable relations between employees and patients, patients' families, visitors, fellow employees, and the medical staff.
• Accepts chain of command, supervision, and constructive criticism.
• Exhibits commitment and pride through personal example by positively speaking about LMC, the department, employees and guests.
• Contributes to teamwork and creates harmonious, effective and positive working relationships with others.
• Respects, understands, and responds with sensitivity to employees and guests by treating others as one would wish to be treated.
• Resolves conflicts and problems-solves by remaining calm when confronted, attempting to identify solutions or referring person to appropriate authority and attempting to deliver more than is expected.
• Demonstrates competence in providing duties within role.
• Serves as role model for other members of the health care team.
• Assists in orientation and training of staff.

Duties & Responsibilities

• Applies appropriate condition codes and modifiers in electronic medical record system to communicate accurate claims information for billing.
• Documents denial information in electronic medical record system including attempts at resolution/overturning of the denial.
• Provides all payor communication to be scanned into the system for use in appeals.
• Maintains good working relationships with other departments within the revenue cycle.
• Conveys and receives information efficiently to and from third party payors, physicians, patients/families, physician practices, other members of the health care team, and other external agencies.
• Consults with attending physician when documentation in the medical record does not support admission or continued stay and seeks to ensure completeness of all clinical documentation.
• Functions as liaison between the Physician Advisor and the attending physician.
• Serves as a resource to physicians, patients, physician practices, and other members of the health care team regarding issues related to patient classification and reimbursement.
• Issues letters of non-coverage in cases where the admission or continued stay is not certified, as necessary.
• Ensures patient/family notification of Observation status and documents in electronic medical record.
• Communicates insurance authorization information to physician's office as requested.
• Communicates with case management triad regarding reimbursement issues.
• Uses appropriate channels for reporting progress or concerns.
• Participates in making appropriate and efficient discharge plans for patients on assigned areas.
• Consults with members of the health care team effectively and efficiently regarding patient discharge plans.
• Manages inpatient Medicare discharge expedited appeals process through the QIO.
• Notifies attending physician and other members of the health care team of inappropriate admissions, denials, end of authorized days, or other factors that have a reimbursement impact.
• Consults Physician Advisor in cases where patient demonstrates readiness for discharge, but there is no documented intent to discharge.
• Identifies and documents potentially avoidable days in electronic medical record system.
• Assists Social Work staff to coordinate/obtain authorization for post acute services as needed.
• Identifies opportunities for improvement and coordinates/participates in the development and implementation of action plans to make improvements.
• Participates in unit discharge planning activities and in interdisciplinary patient care conferences.
• Recommends changes to system/processes to eliminate identified problems.
• Represents department on various committees/taskforces.
• Adapts to change in timely and positive manner.
• Strives to meet department and hospital goals.