Utilization Review Specialist

Description

Summary:

The purpose of the Utilization Management Nurse is to support the physician, the interdisciplinary team, and organization with the underlying objective of enhancing the quality of clinical outcomes while managing the cost of care and providing timely and accurate clinical information to payors. Utilization management provides clinically based first level medical necessity reviews by using standardized published criteria to certify medical necessity for admission and continued stay of all patients receiving care in the hospital. Progression of care is managed by using bench marked evidence-based criteria (i.e., InterQual/MCG).

Responsibilities

• Ensures that Admission Review using InterQual, or MCG is completed within 24 hours of admission.
• Identifies incomplete reviews from work queues.
• Validates admission order on new admits/observations/OP�s daily
• Ensures order in chart coincides with the MCG and/or InterQual review or CMS 2 Midnight Rule for status and level of care
• Resolves any discrepancy at the time of review. If unable to resolve, escalate to PA and CM Leadership
• Delivers the MOON notice to those patients who have been downgraded to Observation status.
• If concurrent case has been determined inpatient by the attending, and case does not meet criteria per first level medical necessity review, discuss case with the attending MD to gather additional clinical information and request additional documentation to support inpatient level of care. If inpatient level of care is still not met, send to PA for second level review
• Identifies reviews that need to be completed and sent to specific payers
• Prioritizes review of all OBS and Outpatients
  
  

10_Concurrent reviews, regardless of payor will be completed every 3-4 days, or more frequently if criteria are waning. Sends concurrent reviews to payor upon request.

• Ensures all days are authorized/certified by respective payers and communicate any issues/denials to department leadership.
• Forwards reviews that require secondary physician review to appropriate resource (Physician Advisor)
• Coordinates with care team in changing LOC/Status, if needed
• Notifies care team, when patient is not meeting medical necessity per InterQual or MCG review and escalate as needed.
• Denotes relevant clinical information to proactively communicate to payers for authorizations for treatments, procedures, and Length of Stay � send clinical information as required by payer.
• Completes and distributes appropriate HINNs.
• Notifies appropriate parties of any changes in financial class including conversions, HINNs and Condition Code 44s
• Maintains and Models Nuvance Health Values.
• Demonstrates regular, reliable and predictable attendance.
• Performs other duties as required.
  
  

Education: ASSOCIATE'S LVL DGRE

Working Conditions

Manual: significant manual skills/motor coord & finger dexterity

Occupational: Little or no potential for occupational risk

Physical Effort: Sedentary/light effort. May exert up to 10 lbs. force

Physical Environment: Generally pleasant working conditions

Company: Danbury Hospital

Org Unit: 152

Department: Care Coordination-DH

Exempt: Yes

Salary Range: $45.29 - $84.11 Hourly