Utilization Review

Utilization Review Specialist

The Utilization Review (UR) Specialist has well-developed knowledge and skills in areas of utilization management (UM), medical necessity, and patient status determination. This individual supports the UM program by developing and/or maintaining effective and efficient processes for determining the appropriate admission status based on the regulatory and reimbursement requirements of various commercial and government payers. This individual is responsible for performing a variety of concurrent and retrospective UM-related reviews and functions and for ensuring that appropriate data is tracked, evaluated, and reported. This individual helps monitor the effectiveness/outcomes of the UM program, identifying and applying appropriate metrics, evaluating the data, reporting results to various audiences, and designing and implementing process improvement projects as needed. This individual helps to identify, develop, and provide orientation, training, and competency development for all appropriate staff and colleagues on an ongoing basis and actively participates in process improvement initiatives, working with a variety of departments and multi-disciplinary staff. Maintains current knowledge regarding commercial and government payers and regulations/guidelines/criteria related to UM. This role is responsible for ensuring that the UM program maintains documented, up-to-date policies and procedures and that all UM key processes have valid outcome measures that are monitored for compliance and reported to appropriate stakeholders. The UR Specialist effectively and efficiently manages a diverse workload in a fast-paced, rapidly-changing regulatory environment. The UR Specialist is a member of and provides support to the hospital's UR Committee. He/she collaborates with multiple colleagues at various levels throughout Sturdy for the purpose of supporting and improving the UM program.

Required Skills/Qualifications/Training/Experience:

• Must be able to facilitate correct identification of patient status (inpatient, observation status) so that appropriate claim can be submitted to commercial and government payers
• Complete short stay reviews (one midnight); track and trend results for reporting and education purposes. Identify opportunities for process and system improvement and initiate and support performance improvement as indicated
• Collaborate with nursing, physicians, admissions, fiscal, legal, compliance, coding, and billing staff to answer clinical questions related to medical necessity and patient status
• Facilitate annual update of InterQual software (collaborating with Information Systems staff), assist in creation of training tools, and provide training as needed to RN CMs
• Knowledge in areas of: Medicare and Medicaid UM regulations, InterQual, Medicare Inpatient Only List, RAC, QIO, MAC, and Denial Management
• Develop review process for OR and ED patients at portals of entry
• Minimum 3-5 years acute care case management experience, with demonstrated skills in utilization review
• Excellent computer skills: Adept at utilizing Excel and other software programs to prepare and present data and trend charts at Utilization Review Committee Meetings
• Demonstrated ability to use critical thinking and problem solving skills in facilitating safe and timely patient transitions of care
• Excellent communication skills and positive interpersonal dynamic in working with a variety of stakeholders across the care continuum, including physicians
• Solid knowledge of all insurance plan regulations including CMS/Medicaid to ensure compliance with all required processes and documentation, while minimizing denials
• Strong analytical ability to interpret patient-related information, evaluate appropriateness of continued stay and/or need for ancillary services, and to reassess discharge planning needs based on daily assessment.
• Ability to successfully utilize industry accepted utilization and or medical management criteria in patient status decision making
• Self-starter able to function independently within the scope of position and licensure, as well as department policies and established goals

Preferred Skills/Qualifications/Training/Experience:

• Experience in Cerner a plus
• Experience in Denials management, maintaining software based tracking of appeal status
• Strength in data analytics to aggregate and monitor utilization data, reporting out on trends and key metrics
• Strong knowledge of revenue cycle activities and CM related impact on same

Educational Requirements:

• BSN Graduate of an accredited school of nursing with advanced degree preferred
• License/Certification: RN with current Massachusetts license required
• CCM (Certified Case Manager) and/or ACMA (Accredited Case Manager)
• Board Certification in Nursing Case Management (RN-BC) through ANCC (American Nurses Credentialing Center)