Reviews admission data to establish the appropriate level of care using Interqual criteria.
Integrates clinical knowledge with billing knowledge to review, evaluate, and appeal clinical denials related to the care provided to the hospitalized patient.
Conducts concurrent reviews to determine the continued need for acute care setting, appropriateness and timeliness of treatments/procedures and to optimize the potential for reimbursement.
Collaborates with the multidisciplinary team to assess and improve the denial management, documentation, and appeals process.
Collaborates with UR Manager and/or physician advisor regarding cases that do not meet established guidelines for admission or continued stay.
Acts as a liaison between physicians and payers, coordinating peer-to-peer phone calls.
Collects and compiles data as required.
Current MA RN licensure
Current MA RN licensure required; Bachelor's degree in nursing, health care administration or a related field preferred or commensurate experience
Three years recent, broad clinical experience in the hospital setting
Experience with utilization management within the last 3 years required
An understanding of the severity of an array illnesses, intensity of service, and care coordination needs
Ability to identify appropriateness of patients admission and level of care needs (inpatient & observation) utilizing Interqual criteria
Knowledged of Interqual required; Allscripts preferred
Strong interpersonal and negotiation skills demonstrated by a positive attitude, pleasant, professional and cooperative demeanor with patients, physicians, colleagues and insurance companies
Knowledge of government and insurance company reimbursement policies in regards to admission criteria, treatment and length of stay
Ability to work independently