The work involves performing professional and non-professional nursing duties to manage the Utilization Review Process at the Erie County Medical Center Corporation. The incumbent is self-directed and autonomous in identifying and resolving issues that impact the resource utilization and reimbursement. Work is performed under the general supervision of the Director of Care Management. Supervision may be exercised over clerical staff and other department staff. Does related work as required.
TYPICAL WORK ACTIVITIES:
Manages the daily activities of the Utilization Review Process to ensure compliance with regulatory requirements;
Supervises staff including work assignments, staffing and scheduling functions and orientation of new employees;
Reviews insurance information ensuring accuracy;
Completes full assessment of plan of care to determine if criteria are met to ensure third party reimbursement and enters data into a utilization database;
Assists in identifying reimbursement trends and drafts proactive approaches to ensure full and timely reimbursements;
Participates in the development of risk reduction strategies for use in the development of third party contracts;
Maintains contact with third party payers; maintains a database of payer issues;
Completes Patient Review Instrument (PRI) forms prior to admission and as needed;
Identifies opportunities to improve resource utilization and implements focus reviews to gather information for potential and actual problems;
Plans the development, implementation and evaluation of improvement actions;
Educates staff about utilization principles and admission and continued criteria;
Prepares and presents reports;
FULL PERFORMANCE KNOWLEDGE, SKILLS, ABILITIES AND PERSONAL CHARACTERISTICS: Thorough knowledge of utilization management concepts, resource management principles and reimbursement methodologies; thorough knowledge of Federal and State regulations as they relate to hospital utilization review, good knowledge of medical terminology related to patient charts; good knowledge of billing procedures and hospital insurance procedures; ability to identify and resolve utilization issues; ability to plan and supervise the work of others; ability to prepare reports and statistics of hospital utilization; ability to establish and maintain effective working relationships; ability to communicate effectively, both orally and in writing; sound professional judgment; organizational skills; initiative; physically capable of performing the essential functions of the position with or without reasonable accommodation.
A) Graduation from a regionally accredited or New York State registered college or university with a Bachelor’s Degree in Nursing, Health Administration or Human Services and five (5) years of behavioral health or medical/surgical registered nursing experience, at least three (3) years of which included hospital based utilization review experience; or:
B) Graduation from a regionally accredited or New York State registered college or university with an Associate’s Degree in Nursing, Health Administration or Human Services and seven (7) years of behavioral health or medical/surgical registered nursing experience, at least three (3) years of which included hospital based utilization review experience; or
C) An equivalent combination of training and experience as defined by the limits of (A) and (B).
Possession of a license and current registration to practice as a Registered Professional Nurse in the State of New at the time of appointment; and
Possession of a certification as a PRI (Patient Review Instrument) Assessor as issued by the New York State Department of Health at the time of appointment.
Erie County Medical Center - 16 months ago