Perform the activities of Utilization Management to include but not limited to confirmation of pre authorization with healthcare benefit payer sources, communication as necessary with benefit providers, response to payer source information requests in a timely manner, and communication with physicians for additional documentation requirements in a timely manner. Oversees and provides assistance with discharge planning, coordinates patient's discharge needs with additional services as necessary.
Director of Nursing/Chief Nursing Officer
DIRECT REPORT: YES
Registered Nurse with a minimum of 2 years clinical experience in an ASC, Surgical Hospital, or acute hospital setting.
Minimum one year of utilization management experience. A combination of at least 1 year of clinical experience and 2 years of utilization management experience would also be considered appropriate.
Familiar with Joint Commission, State and Federal standards/requirements.
Knowledgeable about third party payer source criteria of medical necessity.
Organized and able to meet deadlines consistently. Experienced in team and collaborative approaches to management.
Computer experience required with skills including but not limited to Microsoft Windows, spreadsheets, and word processing.
Performs chart reviews and provides reports on patient's condition to third party payer sources.
Provides information required by third party payer sources within the required time frame.
Uses information management systems to evaluate quality and necessity of care.
Assists and /or consults with facility Administrators to implement and/or maintain a utilization management program to include a process for medical record reviews, reporting to third party payer sources, and measuring effectiveness of the process.
Assists facility in analysis of data to evaluate the effectiveness of processes in place for precertification, concurrent reviews, and retrospective reviews.
Participates in the Utilization Review Committee and attends all meetings.
Participates in preparation of materials requested by Recovery Audit Contractors.
Maintains the integrity of all information submitted for billing to third party payer sources.
Assists in maintaining the Nueterra framework of clinical structure and process standards.
Provides discharge planning support.
Participates as a member of the Clinical Advisory Committee.
Provides data used for tracking, monitoring, and benchmarking activities associated with the appropriateness of admissions, length of stay, denials and outliers.
Assists facilities to achieve high quality, timely, cost effective, and safe patient care delivery.
Operates within the established business unit budget.
Meets facility needs as demonstrated by facility's utilization of resources by timely, accurate and correct billing and payment for services.
Knowledgeable of state, federal, and commercial payer source participation requirements.
Uses professional and industry clinical practice guidelines and recommendations to guide appropriateness of services, length of stay and discharge planning.
Assists in development of utilization management process, provider and staff education of the process and accurate data submission.
Works in a collaborative, team oriented style.
Trains facility professional and clinic staff on current principals, standards of practice of utilization management, medical /surgical diagnosis and treatment coding and reimbursement methodologies.
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job the employee is frequently required to sit, converse, and listen; use hands to touch, handle, or feel objects, tools or controls; and to reach with hands and arms. Specific vision abilities required by this job include close vision and the ability to adjust focus.
The employee must be able to life and/or carry over 20 pounds on a regular basis and be able to push/pull over 25 pounds on a regular basis.
The employee must be able to stand and/or walk at least five hours per day.
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.