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Utilization Review Specialist - Care Management - Saturday & Sunday On

Company: Wyoming Medical Center
Location: Casper
Posted on: August 18, 2019

Job Description:

As a pivotal partner within the health care delivery team, the Utilization Specialist will review charts using Interqual criteria to determine medical necessity of admission and ongoing stay within the hospital. Duties& Responsibilities:

  • The employee shall comply with all safety and health standards, and all rules, regulations, and orders which are applicable to the individual's own position, actions, and conduct.
  • Performs chart reviews in line with current standards and guidelines. These requirements include but are not limited to: Utilization of Interqual ISD Acute Level of Care Criteria for all patient types; Documenting quality indicators for the inpatient population; and Monitoring for appropriate use of patient status (e.g. inpatient/observation).
  • Maintains and applies current knowledge of requirements for insurance providers and special needs associated with Medicaid, Medicare, Workers Compensation, Veterans Administration, and other major programs.
  • Maintains and applies knowledge and clear understanding of full array of hospital processes and care decisions from admission to discharge.
  • Initiates notifications to and telephone reviews with third party payers.
  • Informs inpatient unit manager of patient specific concerns arising from reviews, and keeps Executive Director and/or other appropriate staff informed of special circumstances relating to care utilization.
  • Makes referrals to Physician Reviewer and/or to second-level reviewers as appropriate.
  • Completes appropriate and standardized documentation in Midas and/or other relevant software applications to ensure accurate and timely data and patient records.
  • Assists Case Manager with Hospital Initiated Notice of Non-Coverage (HINN) actions as appropriate.
  • Participates as necessary to develop and implement process improvements (including Lean initiatives) for quality, satisfaction, and revenue maximization. Provides assistance in UR process improvements.
  • Maintains and applies knowledge of current regulatory standards and requirements as set forth by Mountain Pacific Quality Health Foundation or other relevant regulatory and/or accreditation agencies.
  • Processes denial and appeal notices in a timely manner.
  • Works collaboratively with other members of the Care Continuum team to achieve best appropriate care for each patient.
  • Notifies physician(s) of care continuum issues related to insurable coverage.
  • Works with Case Managers to conduct daily collaborative rounds as necessary.
  • Serves as expert resource and provides education to all Case Managers on Utilization Reviews and UR-related requirements. Requirements
    • --- Prior Utilization Review experience is preferred.
    • --- At least five years of job-relevant acute care nursing experience is required.

Keywords: Wyoming Medical Center, Casper , Utilization Review Specialist - Care Management - Saturday & Sunday On, Executive , Casper, Wyoming

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