Job Description

General Summary

Under general supervision, provides utilization review and denials management for an assigned patient case load. This role utilizes nationally recognized care guidelines/criteria to assess the patient’s need for outpatient or inpatient care as well as the appropriate level of care. The role requires interfacing with the case managers, medical team, other hospital staff, physician advisors and payers.

Principal Responsibilities and Tasks

The following statements are intended to describe the general nature and level of work being performed by staff assigned to this classification. They are not to be construed as an exhaustive list of all job duties performed by personnel so classified.

1.           Performs timely and accurate utilization review for all patient populations, using nationally recognized care guidelines/criteria relevant to the payer.

2.           Communicates with clinical care coordinators, physician advisor, medical team and payors as needed regarding reviews and pended/denied days and interventions.

3.           Supports concurrent appeals process through proactive identification of pended/denied days. Implements the concurrent appeals process with appropriate referrals and documentation.

4.           Ensures appropriate Level of Care and patient status for each patient (Observation, Extended Recovery, Administrative, Inpatient, Critical Care, Intermediate Care, and Med-Surg).

5.           Reviews tests, procedures and consultations for appropriate utilization of resources in a timely manner.

6.           Conducts HINN discussions/Observation Education.

7.           Collaborates with Clinical Care Coordinators concerning Avoidable Days Collection.

8.           Ensures Regulatory Compliance related to Utilization Management conditions of participation.

9.           Assures appropriate reimbursement and stewardship of organizational and patient resources.

10.         Pursues and reports opportunities to improve reimbursement.

11.         Collaborates with admitting specialists regarding authorization policies and procedures of third party payers.

12.         Remains current on clinical practice and protocols impacting clinical reimbursement.

Patient Safety

Ensures patient safety in the performance of job functions and through participation in hospital, department or unit patient safety initiatives.

1.           Takes action to correct observed risks to patient safety.

2.           Reports adverse events and near misses to appropriate management authority.

3.           Identifies possible risks in processes, procedures, devices and communicates the same to those in charge.