JOB SUMMARY:
Conducts initial, concurrent and retrospective chart review for clinical, financial and resource utilization information. Provides
intervention and coordination to decrease avoidable delays and denial of payment. Interfaces with 3rd party payers by providing
pertinent, relevant clinical information.
- Reviews the medical record by applying utilization review criteria, to assess clinical, financial, and resource consumption. Enters
clinical reviews into the software program. Maintains close communication with external reviewers/internal financial
counselors/patient access personnel and performs certification activities as required by payor. - Monitors and identifies patterns or trends in utilization management. Monitors potential and actual denials and coordinates with nurse Care Manager and/or Social Worker for any follow up necessary. Documents in software program the actions taken to coordinate care and avoid denials. Assists nurse Care Managers in communicating with the patient denied hospital days as well as the issuance of Medicare forms including HINN, Detailed Notice of Discharge to patients/family/significant other when they are in disagreement with the discharge plan arranged by attending and Care Management personnel.
- Coordinates with the Care Manager to achieve optimal and efficient patient outcomes, while decreasing length of stay and avoid
delays and denied days. Utilizes Physician Advisor and administrative personnel for unresolved issues. Identifies opportunities for expedited appeals and collaborates with the Care Manager and Physician Advisor to resolve payer issues. Other tasks as assigned. - Sends appropriate referrals/escalations to the physician advisors to review case not met with criteria.
REQUIREMENTS:
- Current RN license in MD (or Compact State as applicable)
- Associate's Degree in Nursing required; BSN or higher preferred
- Minimum of 3 years of experience; 5+ years of experience preferred
