Utilization Review Case Manager

Day (United States of America)

Utilization Review Case ManagerThe primary responsibility of the Utilization Review Case Manager is to review medical records, document medical necessity and prepare concurrent clinical appeals (when appropriate) on medical necessity, level of care, length of stay, and authorization denials for hospitalized patients. An understanding of the severity of an array of illnesses, intensity of service, and care coordination needs are key, as the nurse must integrate clinical knowledge with billing knowledge to review, evaluate, and appeal clinical denials related to the care provided to the hospitalized patient. The utilization review nurse works with the multidisciplinary team to assess and improve the denial management, documentation, and appeals process of such findings. The utilization review nurse manages all activities related to the monitoring, interpreting, and appealing of concurrent clinical denials received from third-party payers and ensures accuracy in patient billing. The position is integral to the organization, as successful appeals by the nurse result in preventing denied claims and preserving revenue. Those in the position also work in collaboration with physician advisers to support policy development, process improvement, and staff education related to clinical denial mitigation. 

- Completion of an accredited LPN or RN nursing program
- Three years acute care experience in a hospital setting
- One year as a utilization review nurse preferred
- Strong computer skills required
- Licensed Nurse in the State of Florida
- Demonstrates effective interpersonal and communication skills
- Demonstrates flexibility via an ability to adapt to changing priorities
- Demonstrates good customer relations
- Ability to prioritize assignments and effective time-management skills
- Basic knowledge of clinical and psychosocial aspects of patient care
- Must be detail oriented, flexible, and committed to patient advocacy
- Demonstrates skills in planning, organizing, and managing multiple functions and complex processes
- Excellent verbal and written communication skills required
- Knowledge of basic computer software programs
- Knowledge of area community resources and referrals
- Performs and documents initial certification and continued stay reviews in appropriate time frame and appropriate database
- Obtains information from patient, caregivers, providers of services, insurance company, benefits administrators and others as necessary
- Conveys complete and accurate clinical information to payor throughout certification process
- Researches benefit data and options, programs and other forms of assistance that may be available to the client, and negotiates for services as indicated
- Communicates pertinent reimbursement information to healthcare team while observing patient right to confidentiality
- Verifies in-network verses out-of-network benefits and communicates date to the patient and healthcare team as indicated
- Maintains follow-up communication with payor as required; confirms certification date with payor at time of discharge
- Documents obtained financial information in a complete, timely and concise manner
- Notifies Utilization Review Supervisor, Case Management Director, Medical Director of Utilization Management and/or CMO as appropriate, of all unresolved utilization problems or issues
- Identifies trends in care, processes or services that may provide opportunities for improvement in a patient population, provider population or service unit
- Takes initiative to participate in a quality/process improvement initiative
- Identifies quality and risk management issues; refer issues for corrective action as appropriate
- Collaborates with the interdisciplinary team to create solutions and take corrective actions to address issues resulting in variances in the plan of care
- Evaluates research studies and applies findings to improve case management and service delivery
- Remains at all times a firm patient advocate; seeks to obtain and maintain quality care for all clients regardless of payor type
- Observes at all times legal and ethical considerations pertaining to client confidentiality
- Assumes accountability for facilitating patient’s plan of care throughout their hospital stay
- Contributes to an overall team effort and actively participates in multidisciplinary rounds by communicating information regarding patients meeting medical necessity and level of care
- Serves as a resource for other members of the healthcare team by participates in or conducts formal/informal in-service education as indicated