[Hiring] Case Manager - Utilization Review Specialist @Quorum Health

Role Description

The Utilization Review Specialist assumes responsibility and accountability for admission and concurrent reviews assuring the prevention of denials from all payers, as well as appeals of all accounts reviewed and deemed appropriate for appeal. The Specialist will create a structure for resolution of root cause denial trends by continuously working to identify opportunities for workflow improvements.

Qualifications

• Current state-issued RN license.
• Knowledge in areas such as InterQual Level of Care Criteria and Milliman & Robertson Criteria.
• Knowledge of third party payer regulations related to utilization and quality review is preferred.

Requirements

• Analyzes patient records to determine legitimacy of admission, treatment, and length of stay in health-care facility to comply with government and insurance company reimbursement policies.
• Reviews application for patient admission and approves admission or refers case to facility utilization review committee for review.
• Compares inpatient medical records to established criteria and confers with medical and nursing personnel.
• Abstracts data from records and maintains statistics.
• Determines patient review dates according to established diagnostic criteria.
• May assist the review committee in planning and holding federally mandated quality assurance reviews.
• May supervise and coordinate activities of utilization review staff.
• Research clinical records, appropriate insurance regulations and history of claim to determine next step.
• Monitor day to day compliance of appeal decision time frames and collaborate with other departments.
• Review clinical and medical records for completeness and determine administrative or clinical appeal.
• Assign reviews to physician advisors and medical directors for those requiring medical necessity reviews.
• Coordinate first, second and third level appeals.
• Consults with managers on problem cases and interfaces with case managers, clinical supervisors, account managers and other personnel.
• Ensure proper documentation of all denials into billing systems.
• Manage appeals to ensure timely submissions.
• Monitor volume of appeals in order to engage additional resources when needed.
• Form professional relationships with payer appeals and utilization departments.
• Enter all data related to appeals and case reviews into a database.
• Prepare and present information on appeals to applicable committees and personnel as requested.
• Prepare for and complete appeals audits.
• Monitor and report QI (Quality Improvement) activities of appeals department.
• Demonstrate ability to draft professional appeal letter by incorporating supporting documents, policies and statutes.
• Other duties as assigned.

Company Description