Overview

Oversees the evaluation of patients for appropriateness of admission type and setting, utilizing a combination of clinical information, screening criteria and third-party information across the DCH System. Serves as the primary educator for all DCH PA's, Case Managers, Social Workers, CDI personnel, Utilization Review Coordinators (URC), in the principles of utilization management and serves as a consultant for issues regarding regulations, compliance, payor specific criteria and the denial management process for the DCH System.

Responsibilities

Supervises utilization review professional and clerical employees.

Establishes, manages, approves, and constantly evaluates staffing levels, performance, assignments, skills, learning needs and deployment of Utilization Review.

Responsible to support and participate in DCH System strategies and efforts focused on improving length of stay (LOS) and reducing readmissions.

Ensures orientation and training in Utilization Review for Utilization Review Staff.

Manages the day to day operations for the DCH System Commercial Utilization Review function.

Displays sound managerial judgment in all areas.

Supervises and initiates or recommends personnel actions for Utilization Review staff members.

Manages departmental budget and productivity standards.

Interviews, selects, hires, and retains employees

1 0. Performs compliance requirements as outlined in the Employee Handbook

Approves payroll and is responsible for accurate payment of employees

1 2. Is knowledgeable of hospital mission, vision, and values, and performs in a manner to support them. 1 3. Manages the performance of URCts providing feedback and direction.

1 4. Informs staff of any insurance changes involving InterQual guidelines or in providing clinical reviews.

1 5. Functions as a consultant to staff for solving challenging utilization issues throughout the DCH System.

1 6. Analyzes each of the assigned medical records for the purpose of medical necessity and appropriate billing status.

Collaborates with Business Office Personnel to identify correct insurance source, initial pre-certification information and provides clinical information as necessary to obtain authorization for payment.

Manages utilization of Commercial observation process.

Collaborates with the Case Manager to determine patient's appropriateness for acute hospital level of care,

Evaluates patient's clinical course to verify patients continued need for acute hospital level of care.

Provides third party payers with clinical information as needed to comply with payers' requirements for documentation of medical necessity.

Negotiates a resolution of any DCH System disagreement over the need for acute hospital level of care with the insurer.

Intervenes with appropriate parties regarding inappropriate admissions, delays in discharge and the overutilization of hospital resources.

Intervenes with appropriate individuals regarding delays in service that may have an impact on the quality of patient care and/or length of stay.

Refers appropriately to Performance Improvement and Risk Management for patient safety occurrences and sentinel events.

Refers cases not meeting acute inpatient criteria to the physician advisor and assists with his/her review of the case.

Gathers information for monthly statistical reports, special projects as assigned by the Corporate Director of Case Coordination.

Assists in discharge planning by confirming patient's insurance benefits.

Updates and documents in the computer system pertinent clinical information by utilizing screening criteria.

Maintains records in a complete, detailed and orderly manner.

Identifies potentially avoidable days per department policy.

Establish appropriate staffing levels, assignments, and deployment of Utilization Review staff.

Collaborates with Medical Records and patient Accommodations regarding patient billing status.

Collaborates with the Financial Counselors to facilitate the Medicaid application process.

Manages the delivery of the denial notification for the DCH Health System.

Manages work list of BC/Commercial patients with Hospital acquired conditions/Never Events.

Responsible to support and participate in department strategies and efforts focused on improving length of stay (LOS).

Responsible to support and participate in department strategies and efforts focused on improving clinical documentation by physicians and staff.

Manages the BC/BS's Concurrent Utilization Review program (CURP) for RMC, NMC, and FMC for the DCH System.

Liaison between hospital & payers during concurrent and retrospective medical necessity audits for the DCH System.

Manages continuation of benefits notices issued by Physician Advisor (i.e. pt. notification business office).

Conducts retrospective medical record audits to verify appropriate administration of criteria and reports findings as directed.

Conducts special focused reviews as directed.

Collaborates with the Compliance Officer to assure accurate billing on cases with ambiguous orders.

Supports departmental operations to ensure consistency with health system/departmental policies.

Provides service in the most cost-effective manner, without compromising the quality of care, or customer satisfaction.

Assists Corporate Director of Care Coordination in planning and implementation of opportunities and new ideas to promote department growth and development.

Designs and develops processes related to special projects as assigned by Director.

Maintains, monitors, and audits accuracy of outpatient and inpatient appeals and interventions and observation according to department policies based on medical necessity.

Develops a working knowledge of IMAC's, eFR, and EPSI computer software.

Monitors hospital effectiveness for managing patient billing status, identifies opportunities for improvement and informs leadership through monthly reports.

Manages hospital appeals for reconsideration of denied payment by insurance companies.

Maintains confidentiality at all times related to both patient and employee information.

Manaqer

• Manages departmental budget
• Interviews, selects, hires, and retains employees
• Ensures orientation and training for employees
• Manages performance
• Promotes, demotes, or transfers employees to meet organizational needs
• Executes employee accountability process up to and including termination
• Manages departmental productivity standards
• Performs compliance requirements
• Approves payroll and is responsible for accurate payment of employees
• Manages front line operations of area of accountability related to meeting/exceeding departmental goats

 

 

 

 

DCH Standards:

• Maintains performance, patient and employee satisfaction and financial standards as outlined in the performance evaluation.
• Performs compliance requirements as outtined in the Employee Handbook
• Must adhere to the DCH Mission, Vision, and Values including creating positive relationships with patients/families, coworkers, colleagues and with self.
• Performs essential job functions in a manner that ensures the safety of patients, visitors and employees.
• Identifies and reduces unsafe practices that may result in harm to patients, visitors and employees.
• Recognizes and takes appropriate action to reduce risks and hazards to promote safety for patients, visitors and employees.
• Requires use of electronic mail, time and attendance software, learning management software and intranet.
• Must adhere to all DCH Health System policies and procedures. All other duties as assigned.

Qualifications

Registered Nurse with current Alabama license; very good organizational and interpersonal skills required. Computer knowledge required

At least three years acute hospital Utilization Review experience required Can write legibly and speak and read English.

A minimum of five (5) years Utilization Review experience preferred

Ability to establish priorities, meet deadlines, and maintains proper productivity.

Ability to form positive, collaborative relationships with hospital staff, patients, families and post-acute providers.

Ability to problem solve in a proactive, creative manner, using sound judgment based on factual information and clinical knowledge.

Excellent leadership skills and to serve as a role model for staff.

Ability to lead and actively participate in multidisciplinary teams.

Intermediate computer skills.

Ability to work independently or within a team structure.

Excellent interpersonal skills and communication style.

   

Must be able to read, write legibly, speak, and comprehend English.

 

WORKING CONDITIONS

Is able to lift at least 201bs.

Ability to tolerate prolonged periods of sitting, or standing and/or walking Ability to reach reasonable distances to handle equipment Good manual and finger dexterity.

Hearing and vision must be corrected to within normal range.

Good communication skills.

Physical presence onsite is essential. Hearing and vision must be normal or corrected to within normal range. Able to perform the duties with or without reasonable accommodation.