Utilization Review

Utilization Reviewprovides clinically-based care management to support the delivery of effective and efficient patient care. Has the overall accountability for the utilization management and discharge planning for patients within the assigned caseload. Collaborates with other members of the health care team to identify appropriate utilization of resources and to ensure reimbursement. Utilizes criteria to confirm medical necessity for admission and continued stay. With the patient, family and health care team, creates a discharge plan appropriate to the patient’s needs and resources. Essential Duties and Responsibilities Completes an initial screen of all patients within 24 hours of admission utilizing specific criteria to identify needs related to utilization management and/or discharge planning. Refers appropriate cases to Discharge Planner based on established referral criteria and professional judgment. Integrates the discharge planning/coordination and utilization reviewfunctions in the case management role. Collaborates with all members of the multidisciplinary team to facilitate the care coordination processes for the assigned caseload. Management of Resources and Application of Criteria Evaluates patients for appropriateness of admission type and setting, utilizing a combination of clinical information, screening criteria, and third party information. Validates admission criteria with third party payers, including onsite and telephonic Care Managers, as well as Primary Care and Attending Physicians. Recommends alternative care sites where appropriate. On a daily basis, identifies cases that fail to meet criteria and promptly reviews the case with the patient’s physician to resolve the issue. Refers unresolved cases to the Care Management Director by 3pm of the same day. Collaborates with the third party payers to anticipate denial of payment and proactively addresses issues contributing to a potential denial. Retrospectively addresses denials by reviewing the patient record and care management worksheets. Writes the letter of appeal for pertinent denials. Conducts concurrent admission and continued stay reviews based on appropriate utilization reviewcriteria. Obtains continued stay certification as needed. Assesses the presence of Severity of Illness/Intensity of Service, ISSI, criteria in the patient record. Proactively follows and intervenes on open cases to include concurrent appeals of denials. Provides clinical review, including clinical reviews, to payers in accordance with established standards, procedures and policies. Proactively anticipates concurrent denials and, in collaboration with the Care Manager, intervenes to prevent the denial where possible. Reviews and collects medical records data for quality monitoring, compliance audits, risk management, and clinical outcome reporting as directed. Refers cases to and consults with Care Managers and Social Workers to promote appropriate continued stay or discharge. Refers to and consults with medical staff and other internal staff as needed to facilitate accurate documentation and assure appropriate, timely discharge. Documents authorization and days approved data as outlined in the departmental policy and procedure. Identifies potential barriers to discharge or transfer and communicates them to the care team to spearhead resolution of the issues where possible. Collaborates and communicates with the patient’s interdisciplinary team. Identifies consistent issues related to reimbursement and discharge planning and communicates them to the department leadership. Management of Patient/Family Transitions and Discharges Assesses the patient/family for care needs during hospitalization to establish an effective discharge plan in collaboration with the multidisciplinary team. Identifies patients and families with complex psychosocial issues and makes referrals as appropriate. Communicates clinical information in a clear and timely way. Monitors the patient’s progress and plan of care with the aid of internal and external utilization guidelines. Reports issues and system barriers to efficient and effective discharge planning to the Care Coordination Supervisor. Intervenes as needed when patients vary from the expected plan. Additional Accountabilities Although Care Manager Assignments are unit based, each Care Manager is expected to cross cover other areas as needed and requested. Identifies high-risk patients to promote coordination of services and to prevent readmissions or Emergency Department visits. Strategizes with Primary Care Physicians, attending, specialists, and payers to develop appropriate care delivery strategies for these patients. Documents in the patient record according to department policies and procedures. Accurately completes the Care Manager worksheet on a daily basis. Promptly communicates with attending physicians when cases lack adequate documentation to support acute hospitalization. Contacts the attending physician to notify him/her of all decisions to issue a notice of non-coverage for all payers. Informs the patient and/or next of kin when Medicare coverage must be terminated for the current admission. Issues the termination letter for Medicare patients following established hospital policy. Educates staff and physicians about managed care principles, observation status, discharge planning, reimbursement rules and range of patient care settings beyond observation, intensive care and acute hospital levels. As a member of the Care Management practice: Seeks and provides peer consultation about cases that are presenting problems and/or experiencing significant deviation from the plan of care. Participates in quality improvement and evaluation processes related to the care management practice. Participates in the development of procedures, roles, systems, and structures related to the care management practice. Assists the hospital and the department in meeting and exceeding their commitment to Continuous Quality Improvement. Interacts with patients/families, colleagues, and external contacts with respect, sensitivity and attentiveness to promote teamwork and cooperation. Adheres to Care Management department specific and organizational policies and standards as well as standards from external regulatory agencies and accrediting bodies, i.e., HFAP, AOA, CMS, Department of Public Health, etc. Participates and assists in departmental studies and projects as assigned. Performs basic administrative tasks related to the job, including but not limited to, preparing reports and statistical record keeping. Other duties as assigned. Skills and Abilities Demonstrates the knowledge and skills necessary to provide care appropriate to the age of the patients served. Demonstrates knowledge of the principles of growth and development over the life span. Is able to assess data reflective of the patient’s status and interpret the appropriate information needed to identify each patient’s requirements relative to his or her age-specific needs and to provide the care needed. Maintains confidentiality of all information. Attends mandatory in-service programs. Participates in activities of professional associations as appropriate. Maintains a professional level of conduct and appearance. Practices good public and guest relations by displaying a friendly and cheerful manner. Displays good judgment and tact when dealing with complaints and situations where the policies of the hospital are being enforced. Uses personal judgment and specialized knowledge to give information to people. Communicates well. Speaks clearly and listens carefully. Adheres to policy and procedures as set forth by the hospital. Assists patient and their families in their needs. Ability to multitask. Uses eyes, hands, and fingers accurately while operating a switchboard or computer keyboard. Physical Demands Sedentary Work: Exerting up to 10 pounds of force occasionally and/or a negligible amount of force frequently to lift, carry, push, or pull, or otherwise move objects, including the human body. Environmental Conditions Inside: Protection from weather conditions but not necessarily from temperature changes. Reasoning Development Be able to apply principles of rational systems to solve practical problems and deal with a variety of concrete variables. Interpret and direct a variety of instructions furnished in written, oral, diagrammatic or schedule form. Mathematical Development Add, subtract, multiply, and divide all units of measure. Perform the four operations with like common and decimal fractions. Compute ratio, rate, and percent. Language Development Reading: Read and understand instructions, safety rules, etc. Writing: Write reports with proper format, punctuation, spelling, and grammar, using all parts of speech. Speaking: Speak with poise, voice control, and confidence, using correct English and well-modulated voice. Relationships to Data, People and Things Data: Coordinating: Determining time, place and sequence of operations or actions to be taken on the basis of analysis of data; executing determination of and/or reporting on events. People: Maintaining harmonious relations among coworkers and other people and promoting efficiency. Things: Handling: Using body members, hand tools, and/or special devices to work, move or carry objects or material. Qualification Education and/or Experience: Associates Degree in Nursing, Bachelor of Nursing preferred. A minimum of two years UR/DCP/CM experience in a hospital setting. Valid RN Licensure for State Of Florida. #J-18808-Ljbffr Coral West Community Hospital