Utilization Review - #291650

Capital Region Medical Center


Date: 06/11/2021 10:01 AM

City: Jefferson City, Missouri

Contract type: Full Time

Work schedule: Full Day

Capital Region Medical Center Position Description


Position Purpose: Performs pre-admission, concurrent, and retrospective reviews of by direct contact with inpatients, clinical staff and the medical record using pre-established, objective, quality of care, coding, and medical necessity criteria to monitor patient care rendered. Provides decision support by communicating findings to Case Manager, physician, or others. Negotiates reimbursement directly with payers or refers complex cases to Case Manager and/or Manager. May assist with denials and appeals.


Principal Accountabilities and Essential Duties of the Job:


FINANCIAL



  • Maintains fiscal responsibilities utilizing sound principles
  • Negotiates reimbursement from payers and refers cases to Case Manager as needed
  • Provides notice to patient of non-covered services (under advisement of Physician Advisor and/or Manager of Case Management) after concurrent appeals process is exhausted with commercial insurance provider. Assists Case Manager with issuance of Hospital Issued Notice of Non-coverage (under advisement of Physician Advisor and/or Manager of Case) as needed. Assist Case Manager with issuance of important message from Medicare to Medicare beneficiaries

GROWTH



  • Supports patient care processes to sustain growth and meet strategic plan goals

PEOPLE



  • Communicates and collaborates with team regarding patients statue, needs, goals, and desired outcome
  • Interacts as requested with medical staff, hospital quality improvement committees, and others to facilitate the recognition, and resolution of problems
  • Functions as a team member with Case Manager and social worker

QUALITY



  • Possesses and upholds Continuous Quality Improvement Principles by:
  • Performs and documents pre-admission, concurrent, and retrospective reviews of patient clinical records using pre-established, objective criteria as a standard to evaluate the patient and the information from the clinical staff
  • Completes audits of coding and quality as requested. Enters into database
  • Refers and follows up with record which does not meet criteria to the Case Manager, attending physician or physician advisor
  • Provides notice to patient of non-covered services (under advisement of Physician Advisor and/or Manager of Case Management) after concurrent appeals process is exhausted with commercial insurance provider. Assists Case Manager with issuance of Hospital Issued Notice of Non-coverage (under advisement of Physician Advisor and/or Manager of Case) as needed. Assist Case Manager with issuance of important message from Medicare to Medicare beneficiaries
  • Assists with appeals of denied certifications as needed
  • Assists in gathering and analyzing data, preparing reports, making recommendations, and collaborating with other team members to ensure proper documentation and resource utilization
  • Demonstrates positive customer service/relations

SERVICE



  • Demonstrates positive customer service relations
  • Balances workload between commercial, managed care, and government payers
  • Attends Multidisciplinary Rounds and Outlier Rounds as requested
  • May provide coverage for weekend and holiday coverage as determined by hospital need

Education: Associates Degree


Experience: 1 to 3 years


Certification/Licensure: RN or LPN preferred

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