This role involves assessing patient records to ensure the legitimacy of admissions, treatments, and hospital stays, aligning with government and insurance reimbursement policies. The Utilization Review professional performs utilization review and management, including quality and case reviews for third-party payer requirements. They ensure optimal reimbursement from governmental third-party payers by obtaining proper authorization, verifying medical necessity, appropriate level of care, and regulatory compliance through prospective, concurrent, and retrospective reviews.
Responsibilities
Perform admission reviews (ISD) of Medicare and Medicaid patient records and provide review data to the carrier when requested
Perform admission reviews (ISD) of insurance and HMO patient records and provide review data to the carrier when requested
Maintain a system of monitoring all admissions and ensure timely review of extended stays
Identify length of stay in accordance with established norms
Perform discharge reviews (ISD) of Medicare and Medicaid patient records and advise the physician accordingly
Perform discharge reviews (ISD) of insurance and HMO patient records and provide review data to the carrier when requested
Collect, aggregate, display, and conduct first-level analysis of data obtained from monitoring and evaluating the quality and utilization level of patient care
Conduct medical care evaluation studies concerning patient admissions, duration of hospitalization, ancillary, and professional services
Consult with the department supervisor about admissions under review and study
Report data collected for certification and recertification of patients
Perform retrospective review of records scheduled to be reviewed by PRO
Assist physicians with chart reviews when "Attending Physician Notice" is received
Assist in the preparation of reconsideration letters to the PRO, as needed
Maintain availability to the business office and case management department to assist in specific cases of overuse of hospital resources and disposition/placement related problems affecting lengths of stay
Assist with Medical Diagnostic review and provide carriers with required information
Participate in cross-functional CQI, safety, and infection control studies as assigned
Have flexibility of schedule to meet the needs of the patient and family members for discharge planning, counseling, etc.
Perform other assigned duties as required
Requirements
Associate's degree in nursing, Bachelor of Nursing preferred
A minimum of two years' UR/DCP/CM experience in a hospital setting
Valid RN Licensure for State Of Florida
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Address age-specific needs of adult and geriatric population in all intervention, assessment, and service delivery coordination
Maintain a professional level of conduct and appearance
Practice good public and guest relations by displaying a friendly and cheerful manner
Display good judgment and tact when dealing with complaints and situations where hospital policies are being enforced
Use personal judgment and specialized knowledge to give information to people
Communicate well, speak clearly, and listen carefully
Adhere to policy and procedures as set forth by the hospital
Maintain confidentiality of patient information
Assist patients and their families in their needs
Ability to multitask
Use eyes, hands, and fingers accurately while operating a switchboard or computer keyboard
Be able to apply principles of rational systems to solve practical problems and deal with a variety of concrete variables
Interpret and direct a variety of instructions furnished in written, oral, diagrammatic, or schedule form
Add, subtract, multiply, and divide all units of measure
Perform the four operations with like common and decimal fractions
Compute ratio, rate, and percent
Read and understand instructions, safety rules, etc.
Write reports with proper format, punctuation, spelling, and grammar, using all parts of speech
Speak with poise, voice control, and confidence, using correct English and a well-modulated voice
Important Details
Schedule: Occasionally may require overtime
Physical demands: Sedentary work, exerting up to 10 pounds of force occasionally and/or a negligible amount of force frequently to lift, carry, push, or pull, or otherwise move objects, including the human body
Environmental conditions: Inside, protection from weather conditions but not necessarily from temperature changes
Relationships to Data, People and Things
Data: Coordinating; determining time, place, and sequence of operations or actions to be taken based on analysis of data; executing determination of and/or reporting on events
People: Maintaining harmonious relations among coworkers and other people and promoting efficiency
Things: Handling; using body members, hand tools, and/or special devices to work, move, or carry objects or material
