Employment Type : Full-Time
Performs and documents admission, concurrent and retrospective reviews of patient records using established medical necessity criteria including: Monitor unscheduled admissions to assure appropriate patient type, timely notification of payor, and identify appropriate target LOS. Pre-certify/preauthorize process as assigned. Monitor 23-hour observation to assure conversion to inpatient status if appropriate or discharge. Assist with denial and appeal process. Document avoidable delays/days. Monitor and develop plans of action for patients with extended LOS over that allowed by benefit plan. Monitor admissions according to all third party criteria. Perform retrospective reviews as necessary. Collaborate with payor reviewers to assure appropriate utilization of resources. Provide formal and informal education/in-services to staff and physicians on utilization issues. Assist with development/revision of policies, procedures and service standards. Participate in on-going efforts to improve utilization management process and CQI activities as assigned. Maintain current knowledge of payor criteria/policies related to utilization of resources. Audit charts per request of Patient Accounts and Revenue Recovery. Compile data and statistics for monthly and annual reporting. Maintain clinical expertise in Medical-Surgical, Pediatric and Psychiatric clinical care. Escalate payer issues to attending physicians and hospital leadership. Actively collaborates with the health care team regarding the course of care delivery to ensure timely discharge. Serve as liaison between the payer and the physician. Utilize medical discernment and critical thinking skills on a case by case basis as required for reimbursement maximization. Participate in formal education of payer criteria policies to medical students and Residents Two years of current hospital clinical experience or 2 years of current utilization review experience is required. Excellent written and verbal communication skills required. Preferred Qualifications Knowledge in the application of InterQual and/or Milliman Criteria is preferred. Knowledge of government and private insurance payer guidelines and regulations is preferred. Experience in conflict resolution strongly desired. PHYSICAL DEMANDS Applicants with diverse backgrounds are encouraged to apply.
Registered nurse (RN) licensed in the state of Missouri.
Experience in tertiary care and/or a teaching hospital is preferred.
The physical demands described here are representative of those that must be met with or without reasonable accommodation. The performance of these physical demands is an essential function of the job. The employee may be required ambulate, remain in a stationary position and position self to reach and/or move objects above the shoulders and below the knees. The employee may be required to move objects up to 10 lbs