About This Role
This nursing role focuses on conducting medical certification reviews for acute care facilities and services, ensuring medical necessity using evidence-based guidelines. The nurse recommends the appropriate level of care to physicians and acts as a resource for medical staff on admission qualifications, resource utilization, and documentation requirements.
Responsibilities
- Collaborate with the Central Scheduling Department (CSD) team to provide accurate and complete clinical information for authorization
- Conduct admission reviews for Medicare and Medicaid beneficiaries, private insurance members, and self-pay patients using evidence-based guidelines
- Perform new admission reviews concurrently at the point of entry when the admission order is placed and clinical information is available
- Communicate with admitting physicians and physician advisors when documentation does not appear to support hospital level of care
- Use hospital-approved medical necessity tools to determine level of care for inpatient or observation/outpatient services based on physician documentation, H&P, treatment plan, potential risks, and basis for expectation of a two-midnight stay
- Keep current on all Federal, State, and local regulatory changes affecting delivery or reimbursement of acute care services within Utilization Management
- Use knowledge of national and local coverage determinations to appropriately advise physicians
- Proactively collaborate with admitting physicians to provide accurate level of care determination at the time of review
- Escalate identified progression-of-care/patient flow barriers to appropriate departments
- Actively participate in daily huddles, departmental meetings, and education offerings
- Identify and record episodes of preventable delays or avoidable days due to failure of progression-of-care processes
- Educate members of the patient’s care team on the appropriate access to and use of various levels of care
- Promote use of evidence-based protocols and/or order sets to influence high-quality and cost-effective care
- Serve as a resource person to physicians, care coordinators, physician offices, and billing office for coverage and compliance issues
- Complete all reviews within department-established policies and best practice standards
- Meet department quality standards as established for the department, including Inter-rater Reliability audits and completing all initial, concurrent, and discharge reviews within established time frames
- Perform other duties as assigned
- Actively participate in the department’s performance improvement initiatives
- Possess basic computer skills and knowledge
- Demonstrate expert knowledge of hospital-approved, evidence-based medical necessity tools and local and national coverage determinations
