drjobs Utilization Review Specialist

Utilization Review Specialist

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1 Vacancy
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Job Location drjobs

Danbury, CT - USA

Hourly Salary drjobs

$ 40 - 75

Vacancy

1 Vacancy

Job Description

Description

Position at Danbury Hospital

Summary:

The purpose of the Utilization Management Nurse is to support the physician the interdisciplinary team and organization with the underlying objective of enhancing the quality of clinical outcomes while managing the cost of care and providing timely and accurate clinical information to payors. Utilization management provides clinically based first level medical necessity reviews by using standardized published criteria to certify medical necessity for admission and continued stay of all patients receiving care in the hospital. Progression of care is managed by using bench marked evidencebased criteria (i.e. InterQual/MCG).

Responsibilities:

1Ensures that Admission Review using InterQual or MCG is completed within 24 hours of admission.

2 Identifies incomplete reviews from work queues.

3 Validates admission order on new admits/observations/OPs daily

4Ensures order in chart coincides with the MCG and/or InterQual review or CMS 2 Midnight Rule for status and level of care

5 Resolves any discrepancy at the time of review. If unable to resolve escalate to PA and CM Leadership

6 Delivers the MOON notice to those patients who have been downgraded to Observation status.

7 If concurrent case has been determined inpatient by the attending and case does not meet criteria per first level medical necessity review discuss case with the attending MD to gather additional clinical information and request additional documentation to support inpatient level of care. If inpatient level of care is still not met send to PA for second level review

8 Identifies reviews that need to be completed and sent to specific payers

9 Prioritizes review of all OBS and Outpatients

10Concurrent reviews regardless of payor will be completed every 34 days or more frequently if criteria are waning. Sends concurrent reviews to payor upon request.

11Ensures all days are authorized/certified by respective payers and communicate any issues/denials to department leadership.

12 Forwards reviews that require secondary physician review to appropriate resource (Physician Advisor)

13 Coordinates with care team in changing LOC/Status if needed

14 Notifies care team when patient is not meeting medical necessity per InterQual or MCG review and escalate as needed.

15 Denotes relevant clinical information to proactively communicate to payers for authorizations for treatments procedures and Length of Stay send clinical information as required by payer.

16 Completes and distributes appropriate HINNs.

17 Notifies appropriate parties of any changes in financial class including conversions HINNs and Condition Code 44s

18 Maintains and Models Nuvance Health Values.

19 Demonstrates regular reliable and predictable attendance.

20 Performs other duties as required.

    Education: ASSOCIATES LVL DGRE

    Working Conditions:

    Manual: significant manual skills/motor coord & finger dexterity

    Occupational: Little or no potential for occupational risk

    Physical Effort: Sedentary/light effort. May exert up to 10 lbs. force

    Physical Environment: Generally pleasant working conditions

    Company: Danbury Hospital

    Org Unit: 152

    Department: Care CoordinationDH

    Exempt: Yes

    Salary Range: $40.43 $75.10 Hourly


    Required Experience:

    Unclear Seniority

    Employment Type

    Full Time

    Company Industry

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