Utilization Review Specialist - Care Management - Saturday & Sunday On
Company: Wyoming Medical Center
Posted on: August 18, 2019
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
- Maintains and applies current knowledge of requirements for
insurance providers and special needs associated with Medicaid,
Medicare, Workers Compensation, Veterans Administration, and other
- Maintains and applies knowledge and clear understanding of full
array of hospital processes and care decisions from admission to
- Initiates notifications to and telephone reviews with third
- 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
- 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
- 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
- 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
- Works with Case Managers to conduct daily collaborative rounds
- Serves as expert resource and provides education to all Case
Managers on Utilization Reviews and UR-related 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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