Utilization Review

Job Description

Job Description

JOB SUMMARY:

Assesses patient records to determine legitimacy of admission, treatment, and length of stay in hospital to comply with government and insurance company reimbursement policies. Performs utilization review and management, including quality review, case review for third party payers’ requirements. Ensures optimal reimbursement from governmental third-party payers’, obtaining proper authorization. A strong utilization review professional ensures medical necessity, appropriate level of care, accurate reimbursement, and regulatory compliance by conducting prospective, concurrent, and retrospective reviews, applying evidence‑based criteria, coordinating with providers and payers, and preventing denials.

ESSENTIAL RESPONSIBILITIES:

·       Performs admission reviews (ISD) of Medicare and Medicaid patient records and provides review data to the carrier when requested.

·       Performs admission reviews (ISD) of insurance and HMO patient records and provides review data to the carrier when requested.

·       Maintains a system of monitoring all admissions and ensures review of extended stay in a timely manner.

·       Identifies length of stay in accordance with established norms.

·       Performs discharge reviews (ISD) of Medicare and Medicaid patient records and advises the physician accordingly.

·       Performs discharge reviews (ISD) of insurance and HMO patient records and provides review data to the carrier when requested.

·       Collects, aggregates, displays and conducts first level analysis of data obtained from monitoring and evaluating the quality and utilization level of patient care.

·       Conducts medical care evaluation studies concerning patient admissions, duration of hospitalization, ancillary and professional services.

·       Consults with department supervisor about admissions under review and study.

·       Reports data collected certification and recertification of patients.

·       Performs retrospective review of records scheduled to be reviewed by PRO.

·       Assists physicians with review of charts when “Attending Physician Notice” is received.

·       Assist in the preparation of reconsideration letters to the PRO, as needed.

·       Maintains availability to the business office and case management department to assist in specific cases of overuse of hospital resources and disposition/placement related problems affecting lengths of stay.

·       Assists with Medical Diagnostic review and provides carriers with required information.

·       Participates in cross-functional CQI, safety and infection control studies as assigned.

·       Required to have flexibility of schedule to meet the needs of the patient and family members for purpose of discharge planning, counseling, etc.

·       Occasionally may require overtime.

Performs other assigned duties as required.

SKILLS AND ABILITIES:

·       Address age specific needs of adult and geriatric population in all intervention, assessment, and service delivery coordination.

·       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.

·       Use personal judgment and specialized knowledge to give information to people.

·       Communicate well. Speaks clearly and listens carefully.

·       Adheres to policy and procedures as set forth by the hospital.

·       Maintains confidentiality of patient information.

·       Assist patients 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 based on 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:

·        Associate’s 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