Job Abstract

Utilization management (UM) is the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of the applicable health benefits plan.

Prior authorization that allow payers, particularly health insurance companies to manage the cost of health care benefits by assessing its appropriateness before it is provided using evidence-based criteria or guidelines. Strong utilization management process can reduce payment denials.

Clinical documentation specialists is designed to improve the physician’s documentation in the patient’s medical record, supporting the appropriate severity of illness, expected risk of mortality and complexity of care of the patient.

Clinical documentation is responsible for extensive collaboration with physician is, nursing staff, support staff, other patient caregiver and medical records coding staff.

Employee insurance liaison

Meadville Medical Center has self-funded insurance. One staff member is assigned to work with Human resources, Highmark Liaison, Medical director and employees. Set process is to call medical procedures out of network and employee needs to request a waiver from our current liaison. The liaison will review the requested procedure with our current medical director. If the request is approved the liaison of UM will notify the employee and out Highmark Liaison.

Medical necessity rules will be reviewed, urgency and medical history. The decision will be called to the employee. If it is not favorable, this can be appealed to human resources

If this process is not followed, and the employee gets a bill. The liaison will review what was performed. They will review with the medical director and make a decision to override the out of network rules.

The liaison support HR represented as needed.

Applicate:

Curious and Detailed Oriented. Actively seek out new ideas, possibilities, and answers to the tough questions.

Pays meticulous attention to detail.

Committed to life-long learning

UM Process

• Payors may use different criteria and may require their data set be applied for their population.
• Utilization management is a strategy for managing cost and quality under the latest CMS reimbursement
• Reviews precertification requests for medical necessity, referring to the Medical Director those that require additional expertise.
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• Reviews Clinical information for concurrent reviews, extending the length of stay for inpatients as appropriate.
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• Establishes effective rapport with other employees, professional support service staff, customers, clients, patient’s families and physicians.
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• Use effective relationship management, coordination of services, resource management, education, patient advocacy and related interventions.

CDS-Inpatients

• Advanced clinical expertise and extensive knowledge of complex disease processes with a broad clinical experience in an inpatient setting required

• Pursues a subsequent review of records every 3 days to support and assign a working DRG assignment upon discharge.
• Formulates queries when it is determined there is missing documentation, conflicting documentation or unclear documentation.
• Provides on-going education to physicians and essential healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the patient's record.
• Use of coding nomenclature demonstrated knowledge of ICD-10 classifications, and thorough understanding of the effect coded data has prospective payment, outcome models, utilization, and reimbursement.
• Participates in the analysis and trending of statistical data for specified patient population; identifies opportunity for improvement.
• Promotes a partnership with the inpatient-coding professionals to ensure the accuracy of principal diagnosis, procedures and completeness of supporting documentation to determine the working and final DRG, severity of illness and risk of mortality.
• Acts as a resource person for the interdisciplinary team in order to promote collaboration and coordination of patient care considering age specific, developmental, cultural, and spiritual needs of the patient.

Overall department goals

Promotes improved quality of care and/or life.

Promotes cost effective medical outcomes.

Prevents hospitalization when possible and appropriate.

Promotes decreased lengths of observation stays or inpatient stays when appropriate.

Provides for continuity of care.

Assures appropriate levels of care are received by our patients.

Participates in rounding on the nursing floors.

Works with HIM on coding issues.

Provides advice and counsel to precertification staff in physician offices or in house.

Identifies appropriate alternative resources and demonstrate creativity in managing each case to fully utilize all available resources.

Maintains accurate records of all communications and interventions.

Other duties as assigned.

MINIMUM EDUCATION, KNOWLEDGE, SKILLS, AND ABILITIES REQUIRED

Proof of successful completion of education requirements for board certified registered nurse as defined by the state in which the employee is to practice as well as proof of such licensure in good standing. Must have at least 5 years’ experience as a Registered Nurse.

Ability to read analyze and interpret documents, reports, technical procedures, governmental regulations and correspondence

BLS required.

Certification for UM nurse and CDI specialists is encouraged