|Utilization Review Specialist|| |
|Department:|| St. Dominic Behavioral Health Services|
|Job Summary:||Conducts precertification reviews; performs concurrent reviews of patient records for appropriateness of admission and continued stay review as required for certification and reimbursement by third party payors; communicates with physicians regarding concerns about admissions, services, or continued stay. Verifies insurance benefits when needed and reviews benefits, reporting fiscal issues to supervisor. Is able to exhibit cooperation with members of the treatment team including the physician. Is able to recognize and acknowledge the value of other members of the treatment team. Reports to|
Patient Access Coordinator.
- Verifies insurance benefits when necessary and communicates this as necessary to those patients involved.
- Conducts precertification reviews.
- Performs initial review of patient records and communicates with third party payors the information necessary to certify the admission.
- Performs continued stay reviews of patient records at intervals as specified by third party payors communicating with them information as necessary to certify the continuing stay. Utilizes information from all members of the treatment team as indicated to assist in establishing medical necessity for treatment.
- Communicates with physicians concerns about the admissions, services, or continued stay,
- Records precertification and on-going certification in designated manner including the AS400 system with emphasis on input into the CNE notes.
- Conducts follow-up of appeals in a timely manner and reports denials, appeals and status on a weekly basis to supervisor for weekly report to fiscal services.
- Conducts follow-up of retrospective reviews in a timely manner and reports the date sent and results in weekly report to supervisor for report to fiscal services.
- Spends only amount of time on nursing units as necessary to review documents on chart that are not on the computer systems. Makes calls to third party payors as necessary from the privacy of office.
- Audits medical records on an ongoing basis as a means to assess and measure clinical practice patterns with respect to appropriate utilization of services.
- Audits medical records on an ongoing basis to identify appropriate measures to improve the delivery and utilization of patient care services.
- Maintains daily log of review activities including appeals and retrospective reviews and submits these to supervisor on a daily or weekly basis as requested.
- Cooperates with social services/counselors in referral of patients for discharge planning.
- Cooperates with fiscal services to facilitate resolution of concerns involving reimbursement.
- Reports unresolved problems to supervisor.
- Conducts bill audits when necessary reporting results to supervisor, fiscal services, and if indicated, the patient / patient representative.
- Follows chain of command as established for department and facility.
- Is able to follow hospital and department specific policies and procedures and updates.
- Carries out requests of supervisor as related to work group goals of department or the overall efficiency of the department.
- Conducts self in manner to convey a positive sense of team cooperation.
- Supports and interprets hospital's Christian mission, philosophy and objective.
- Maintains confidentiality of patients and other pertinent information.
- Enhances professional growth and development through participation in educational programs, current literature, inservice meetings, and workshops.
- Attends meetings as required.
- Represents behavioral health services to referral sources, community agencies, social services agencies and others as requested.
|Qualifications:||Must be a graduate of a state accredited nursing program with a current MS license with at least 3 years of experience in the field and at least 1 year in utilization review or case management experience. Must be able to communicate with medical staff and members of the treatment team in such a manner as to gain cooperation with regard to utilization review activities. Must have the ability to function independently. This position has been determined to have a mid to high risk of exposure to blood-borne pathogens.|