Virtual Utilization Review Specialist

CAREER OPPORTUNITY OFFERING:

• Bonus Incentives

• Paid Certifications

• Tuition Reimbursement

• Comprehensive Benefits

• Career Advancement

• This position pays between $28.90 $35.45/hrbased on experience

We are seeking Virtual Utilization Review Specialists to join our team. Essential job function include:

Resource Utilization

• Utilizes proactive triggers (diagnoses cost criteria and complications) to identify potential over/under utilization of services

• Initiates appropriate referral to physician advisor in a timely manner

• Understands proper utilization of health care resources and assists with identifying barriers to patient progress and collaborates with the interdisciplinary team

• Collaborates with financial clearance center patient access financial counselors and/or business office regarding billing issues related to third party payers

Medical Necessity Determination

• Conducts medical necessity review of all admissions. Utilizes approved clinical review criteria to determine medical necessity for admissions including appropriate patient status and continued stay reviews possibly from an offsite location

• Provides inpatient and observation (if indicated) clinical reviews for commercial carriers to the Financial Clearance Center (FCC) within one business day of admission

• Communicates all medical necessity review outcomes to inhouse care management staff and relevant parties as needed

• Collaborates with the inhouse staff and/or physician to clarify information obtain needed documentation present opportunities and educate regarding appropriate level of care

• Collaborates with the financial clearance center patient access financial counselors and/or business office regarding billing issues related to third party payers

Denial Management

• Coordinates the P2P process with the physician or physician advisor FCC Revenue Cycle team when necessary and when assigned and maintains documentation relevant to the appeal process.

• Maintains appropriate information on file to minimize denial rate

• Assist in recording denial updates; overturned days and monitor and report denial trends that are noted

• Monitor for readmissions

Quality/Revenue Integrity

• Demonstrates active collaboration with other members of the health care team to achieve the outcomes management goals including CMS indicators

• Accurately records data for statistical entry and submits information within required time frame

• Responsible for ConnectCare and ADT work queues assigned to VUR for revenue cycle workflow

• Accurately records data for statistical entry and submits information within required time frame

• Documentation will reflect all work and communication related to the FCC payor physician physician advisor and inhouse care management

• Secondlevel physician reviews will be sent as required and responses/actions reflected in documentation

Facilitation of Patient Care

• Prioritizes patient reviews based on situational analysis functional assessment medical record review and application of clinical review criteria

• Collaborates with the inhouse care manager Maintains rapport and communication with the inhouse care manager Demonstrates the knowledge and skills necessary to provide care appropriate to the age of the patients served on his or her assignment

• Demonstrates knowledge of the principles of growth and development of the life span and possesses the ability to assess data reflective of the patients status and interprets the appropriate information needed to identify each patients requirements relative to his or her age specific needs and to provide the care needed as described in departmental policies and procedures

Communication

• Directs physician and patient communication regarding noncoverage of benefits

• Maintains positive open communication with the physicians nurses multidisciplinary team members and administration

• Educates hospital and medical staff regarding utilization review program.

• Maintains a calm rational professional demeanor when dealing with others even in situations involving conflict or crisis

• Voicemail Skype and email will be utilized and answered in timely fashion. Hospital provided communication devices will be used during work hours.

• Staff is expected to respond and/or acknowledge communication from the FCC via approved communication guidelines and standardized serviceline agreements

• Staff must be available as designated for meetings or training onsite or online unless prior arrangements are made

Team Affirmation

• Works collaboratively with peers to achieve departmental goals in daily work as evidenced by appropriate and timely communication which is respectful and clear. Sensitive to workload of peers and shares responsibilities fills in and offers to help

• Actively participates in departmental process improvement team; planning implementation and evaluation of activities

• Provides backup support to other departmental staff as needed

Other Job Functions

• Complies with FCC and department policies and procedure including confidentiality and patients rights.

• Maintains clinical competency and current knowledge of regulatory and payer requirements to perform job responsibilities (i.e. medical necessity criteria MSDRGs POA).

• Actively participates in departmental meetings and activities.

• Participates in FCC and community committees as assigned.

• Actively participates in conferences committees and task forces as directed by the FCC division.

• Associates may be required to perform other jobrelated duties as required by their supervisor subject to reasonable accommodation.

Experience:

• Bachelors Degree or equivalent experience; Specialty/Major: Nursing or related field

• Current unrestricted LPN or RN license required; RN compact license preferred

• Three years nursing experience in an acute care environment required

• Utilization review/discharge planning experience preferred

• Recent experience or working knowledge of medical necessity review criteria preferred

• Current working knowledge of quality improvement processes

Other Knowledge Skills and Abilities Required:

• This is a remote role which requires access to high speed internet

• Excellent interpersonal communication and negotiation skills in interactions with physicians payors and health care team colleagues

• Commitment to exceptional customer service at all times

• Communicate ideas and thoughts effectively verbally and in writing

• Strong clinical assessment organization and problemsolving skills

• Ability to assess and identify appropriate resources internal and community on assigned caseload and to work collaboratively with health care team providers and payors to achieve the desired patient quality and financial outcomes

• Ability to prioritize organize information and complete multiple tasks effectively in a fastpaced environment

• Resourceful and able to work independently

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