Utilization Review Specialist

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. Reviews physician medical record documentation and consults with physicians regarding completeness.

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
Substitutable Education & Experience: None.
Required Certifications/Licensure: Registered Nurse currently licensed in the State of South Carolina
Required Training: None.

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.
• Exhibits telephone courtesy by:          
  • Answering promptly with name and department.       
  • Speaking with pleasant tone while focusing on caller.      
  • Transferring calls correctly and promptly.        
  • Attending to calls on hold in a timely manner.
• Maintains confidentiality by:           
  • Discouraging gossip.           
  • Using discretion when discussing patient, work, or LMC-related information with others.
• Utilizes the service recovery process to resolve complaints (GIFT).
• Demonstrates competence in providing duties within role.
• Demonstrates competence to provide developmentally appropriate planning/review for patients of all age groups.
• Identifies need for professional growth and seeks appropriate professional development opportunities attaining a minimum of 15 hours of continuing education in topics related to the role annually.
• Serves as role model for other members of the health care team.
• Demonstrates receptiveness to change and flexibility in meeting department needs.
• Assists in orientation and training of staff.
• Performs admission and continued stay medical record review to gather information to support medical necessity of the admission and communicate with third party payors.
• Performs timely review of admissions utilizing InterQual criteria to assess for appropriate level of care assignment.  Reviews both inpatient admissions and patients placed in Observation.
• Incorporates applicable governmental regulatory guidelines in effect for Medicare and/or Medicaid admissions.
• Submits clinical data to third party payors and documents authorization in electronic medical record system.
• Performs continued stay reviews based on intensity of service, clinical response to care, expected length of stay and readiness for discharge, or at intervals which correspond to authorized days.
• Refers Observation or Inpatient admissions that lack documented medical necessity for the stay to the Physician Advisor and completes any needed follow through to ensure correct level of care and billing based on the Physician Advisor’s determination.
• Documents pertinent clinical data on worksheets.
• Ensures regulatory compliance and revenue integrity utilizing appropriate billing policies.
• Certifies Medicare admission utilizing established admission screening criteria.

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.
• Respects patient confidentiality and uses discretion in all interactions regarding patient protected health information.
• 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.
• Assist 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.
• Indentifies abnormal patterns of utilization and refers to Manager/Director.
• 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.
• Performs all other duties as assigned by authorized personnel or as required in an emergency (e.g., fire or disaster).