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Munson Healthcare Utilization Review Specialist in Traverse City, Michigan

ENTRY REQUIREMENTS

A Bachelor’s degree in Nursing is preferred. For those hired into this position after January 1st, 2015, it is required to obtain a BSN within 5 years of start date.

Current licensure as Registered Nurse in the State of Michigan.

Minimum of three years clinical experience required. Previous utilization review and/or case management in a hospital or insurance industry preferred experience preferred.

Demonstrates effective verbal and written communication skills with internal and external customers, i.e., insurance companies, case managers, home care agencies, physicians, nursing staff and ancillary personnel.

Demonstrated ability to successfully work as part of a team.

Computer skills (Microsoft Office, Outlook, Internet, typing skills) required; able to adapt to required software programs which support Utilization Management functions. Familiarity with health care documentation systems preferred (i.e. Cerner PowerChart, FirstNet)

Demonstrated creative problem-solving skills and a strong attention to detail and accuracy required

Experience and knowledge in discharge planning – preferred

Possess knowledge of managed care insurance, governmental health programs, HMO’s and their impact on hospital and post hospital care reimbursement.

Must be able to work independently, anticipate and organize workflow, prioritize and follow through on responsibilities.

Must possess the strong clinical assessment and critical thinking skills necessary to provide utilization review responsibilities. Superior organization and time management skills required; able to skillfully manage a high-volume caseload and to respond effectively to rapidly changing priorities

ORGANIZATION

Reports to Manager of Case Management.

Works collaboratively with: Case Management, Risk Management, Medical Staff, Nursing Services, Ancillary Departments, Medical Records, Patient Access Services, and Business Office, as well as other disciplines within Utilization Management.

AGE OF PATIENTS SERVED

Cares for patients in the age category(s) checked below:

X All ages (birth & above) _ Infant (1 mo – 1 yr)

_ Neonatal (birth – 1 mo) _ Young adult (18 yrs – 25 yrs)

_ Adult (26 yrs – 54 yrs) _ Adolescence (13 yrs -17 yrs)

_ Early childhood (1 yr - 5 yrs) _ Sr. Adult (55 yrs - 64 yrs)

_ Late childhood (6 yrs -12 yrs) _ Geriatric (65 yrs & above)

_ No direct clinical contact with patients

SPECIFIC DUTIES

  1. Supports the Mission, Vision and Values of Munson Healthcare.

  2. Embraces and supports the Performance Improvement philosophy of Munson Healthcare.

  3. Promotes personal and patient safety.

  4. Has basic understanding of Relationship-Based Care (RBC) principles, meets expectations outlined in Commitment to my Co-workers, and supports RBC unit action plans.

  5. Uses effective customer service / interpersonal skills at all times.

  6. Maintains compliance with state and federally mandated regulations; maintains current knowledge of regulatory changes impacting utilization management and insurance authorization.

  7. Coaches, provides feedback, and guides others in a collaborative and mutually supportive environment; serves as a resource for others with less experience.

  8. Maintains standards of professional practice.

  9. Performs other duties and responsibilities as assigned.

KEY AREAS OF REPSONSIBILITY

Admission

  1. Reviews available documentation to assess all admissions for appropriate status and services according to patient condition and diagnosis.

  2. Applies standard guidelines to determine appropriateness for inpatient level of care or observation services based on documented condition plan of treatment and care.

  3. Supports physician decision-making by coaching on appropriateness of inpatient or observation status.

  4. Confers with admitting physician if documentation does not support hospital level of care to offer alternatives.

  5. Refers cases to the Physician Advisor when documentation is inadequate to support acute level of care and remains unresolved after discussing with referring/attending physician.

  6. Understands and applies federal law regarding the use of Hospital Initiated Notice of Non-Coverage (HINN) and Ambulatory Benefit Notice (ABN).

  7. Monitors insurer compliance with contractual obligations.

  8. Maintains proficiency in the use of electronic review applications including CERMe and EMR and enters information correctly, consistently and timely.

  9. Maintains proficiency in the use of hospital information systems to access information and record data.

Continuing Stay

  1. Actively participate in daily huddles, patient care conferences, and hospitalist/nurses hand-off reports to maintain knowledge about the patient’s clinical status and progression of care.

  2. Consults with case manager and/or physician advisor as necessary to resolve progression-of-care barriers through appropriate administrative and medical channels.

  3. Identify potentially unnecessary services and care delivery settings and recommend alternatives when appropriate.

  4. Collaborates with community physicians and hospitalists to influence transition from one level of care to another.

  5. Notifies insurers and third party administrators of clinical review information.

  6. Maintains documentation on each patient to include specific criteria that support appropriate level of care and continued stay. Performs status changes as necessary

  7. Refers cases to the Physician Advisor when treatment plan documentation does not support acute level of care. Monitors timeliness of PA response.

  8. Identify and record episodes of preventable delays or avoidable days due to failure of progression-of-care processes.

  9. Promote physicians’ use of evidence based protocols and/or order sets to influence high quality and cost effective care.

Transition

  1. Collaborate with clinical team to confirm benefit eligibility for post-acute services.

  2. Apply Interqual/Milliman discharge screens to assess patient’s readiness for a lower level of care.

  3. Updates all involved parties regarding potential, threatened or actual denials due to lack of medical necessity or barriers to the progression of care.

  4. Participates in reviewing 30-day Readmissions as directed by program manager.

  5. Reviews request for direct admissions and transfers for appropriate level of care.

  6. Coordinates with ED Case Manager to recommend alternate placement from the ED when patients do not qualify for Outpatient Observation or Inpatient status

Program Support

  1. Serves as a resource person to physicians, case managers, physician offices, and billing office for coverage and compliance issues.

  2. Works closely with decision support personnel to review resource utilization data and trends to identify outliers who may benefit from real time coaching to improve outcomes.

  3. Encourage healthcare team members in collaborative problem solving regarding appropriate use of resources.

  4. Assists in developing and revising policies to support utilization management activities, including criteria and guidelines for appropriate use of services, clinical practice guidelines and treatment protocols.

  5. Recognizes and responds appropriately to risk factors.

  6. Keeps current on all regulatory changes that affect medical necessity or reimbursement of acute care services and shares that information with program colleagues and hospital associates at information meetings.

  7. May represent Utilization Management on various committees, professional organizations, physician or and community groups

  8. Establish and maintain effective professional working relationships with patients, families, interdisciplinary team members, payers and external case managers

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