The Physician Review Services (PRS) Clinician is accountable and responsible for reviewing peer review outcomes and the quality management of same in accordance with Utilization Management Policies and procedures. The position is accountable for ensuring all peer reviews meet all governance and client requirements in terms of content and medical relevancy as well as responsible for the tasks associated with completing a peer review. This position is very independent and the incumbent must be able to self-manage tasks and time based on defined turnaround times and client regulations.
Education/License/Certification: Licensed healthcare professional (RN, LCSW, LMHC, LMFT, Phd., or PsyD) with a current, unrestricted license required. BSN is preferred.
Experience: One to two years of experience in Utilization review, quality assurance, discharge planning or other cost management programs preferred. One to two years directly related experience using InterQual criteria or healthcare criteria preferred. Two (2) years experience in hospital-based nursing required. Medical-surgical care experience preferred for positions in medical management areas. Behavioral health experience in multiple levels of care for Behavioral Health Utilization Management preferred.
Knowledge/Skills: Strong communication, documentation, clinical and critical thinking skills essential; working knowledge of utilization management/case management preferred; strong problem solving and decision making skills essential; must be computer literate with fluency in Excel, Word and Access preferred.
Quality Management of Peer Reviews:
Reviews all returning Peer Reviews ensuring all Quality Management standards are met. These standards include:
Comprehensive Rational that includes clinical criteria points
Requests for Appeals from the Attending Physician are processed
Appropriate documentation for additional research that may have been conducted is included and referenced
By processing system use, ensure all points of the review/appeal are accurately completed. This will require use of multiple systems.
Completion of the Review
Communicates directly with physician providers/designees when appropriate to gather all clinical information to determine the medical necessity of requested healthcare services;
Communicates directly with the designated medical director regarding all inpatient cases and outpatient/ambulatory requests for health care services that do not meet medical necessity or appropriate level of care and out of network transfer issues;
Communicates all UM review outcomes in accordance with the health plan client profile procedures;
Follows relevant client time frame standards for conducting and communicating UM review determination;
Maintains and submits reports and logs on review activities as outlines by the UM program operation procedures and in accordance with PRS Policies;
Identifies and communicates to the Director of Behavioral Utilization Management supervisor all potential quality of care concerns;
Contacts, via fax, telephone and/or US Mail the outcomes of Peer Reviews as directed by UM/PRS policy and procedures
Health Integrated - 12 months ago
Health Integrated was founded in 1996 and was the nation's first organization to deliver health management solutions using a whole-patient a...