What are the responsibilities and job description for the Utilization Review Specialist position at Nebraska Methodist Health System?
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Purpose of Job
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Performs utilization review functions, manages the denial process and participates in the discharge planning process.
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Job Requirements
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Education
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Successful completion of annual mandatory education requirements.
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Graduate of an accredited nursing program required.
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Experience-
A minimum of two years of clinical experience to gain medical surgical knowledge to be able to apply criteria to determine appropriate level of care.
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License/Certifications-
Current valid license, valid compact multi-state license, or a temporary permit while awaiting licensure required for work state.
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Registered Nurse License
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Skills/Knowledge/Abilities-
Interpersonal skills necessary in order to review and communicate effectively with external and internal customers.
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Computer knowledge.
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Physical Requirements
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Weight Demands
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Light Work - Exerting up to 20 pounds of force.
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Physical Activity-
Not necessary for the position (0%):
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Climbing
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Crawling
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Kneeling
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Occasionally Performed (1%-33%):
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Balancing
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Carrying
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Crouching
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Distinguish colors
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Grasping
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Lifting
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Pulling/Pushing
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Standing
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Stooping/bending
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Twisting
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Walking
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Frequently Performed (34%-66%):
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Fingering/Touching
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Keyboarding/typing
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Reaching
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Repetitive Motions
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Sitting
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Speaking/talking
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Constantly Performed (67%-100%):
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Hearing
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Seeing/Visual
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Job Hazards-
Not Related:
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Chemical agents (Toxic, Corrosive, Flammable, Latex)
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Physical hazards (noise, temperature, lighting, wet floors, outdoors, sharps) (more than ordinary office environment)
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Equipment/Machinery/Tools
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Explosives (pressurized gas)
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Electrical Shock/Static
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Radiation Alpha, Beta and Gamma (particles such as X-ray, Cat Scan, Gamma Knife, etc)
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Radiation Non-Ionizing (Ultraviolet, visible light, infrared and microwaves that causes injuries to tissue or thermal or photochemical means)
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Mechanical moving parts/vibrations
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Rare (1-33%):
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Biological agents (primary air born and blood born viruses) (Jobs with Patient contact) (BBF)
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Essential Job Functions
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Essential Functions I
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Performs utilization review functions in compliance with department guidelines.-
Performs admission and concurrent reviews for medical necessity on all cases utilizing Milliman Criteria.
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Documents clinical reviews (admission, continued stay, secondary) in Milliman using appropriate criteria level (ambulatory, observation, inpatient, acute, intermediate, ICU, NICU).
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Selects RRG criteria in Milliman for screening for majority of reviews.
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Provides timely medical information to payers and receives authorization.
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Verifies authorization of services and communicates information to case management/nursing team.
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Collaborates with other members of the UR team to ensure UR functions completed each day.
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Directs UR Financial Clearance Specialists to verify payer source as needed.
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Manages the accuracy of patient status (inpatient/observation) and level of care. (leveling)
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Documents accurately in UM documentation avoidable days, denials, & peer to peer reviews.
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Refers self-pay patients to MASH if not already done.
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Appropriately refers cases to Physician Advisor for review when severity of illness and intensity of service do not meet ordered admission status and/or payer does not concur with hospital identified level of care or status.
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Follows recommended workflow and documentation guidelines for department. Uses Case Management work list to direct priorities for the day using sorting function.
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Makes decisions based on evidence based practice, research, and UR nurse higher order critical thinking skills and experience.
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Follows Payer Aligned Processes-
Develops/maintains positive working relationship with payer nurse reviewer.
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Participates in payer meetings.
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Provides feedback for improvement in processes related to specific payers.
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Accesses payer website to research preauthorization requirements.
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Submits preauthorization information to payer for medications, cardiac event monitors.
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Identifies and communicates to department manager opportunities to address during contract negotiations.
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Provides information for inclusion in Payer Information spreadsheet.
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Maintains knowledge of Payer requirements regarding length of stay for observation and transition to Inpatient
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Maintains knowledge of Payer requirements for peer to peer process, Skilled nursing facility authorization, & LTAC reviews.
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Manages the denial process for Inpatients, Observation patients, and continued stay reviews.-
Coordinates the denial/appeal process. Interacts with the attending physician and Physician Advisor to review and address adverse reimbursement decisions of managed care organizations.
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Upon direction of Physician Advisor, delivers denial letter to the patient, legal guardian, or health care power of attorney for all payer sources.
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Communicates to Business Office and Clinical Denials and Appeals pertinent information regarding denials of payment and/or levels of care.
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Documents actions taken and outcome(s) in Cerner Case Management tool, payer information.
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Issues Medicare Outpatient Observation Notification (MOON) letter following Condition Code 44 process.
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Completes Medicare discharge appeal process, providing timely information to QIO. Checks QIO website for case progression and outcome. Notifies other team members of appeal and outcome.
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Participates in discharge planning process.-
Is knowledgeable about the medical plan of care.
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Attends and actively participates in interdisciplinary rounds. Communicates pertinent information regarding; covered/approved days, DRG LOS (diagnosis-related group and length of stay) projections, criteria for continued stay, patient benefits, and if patient is not meeting SI/IS (medical necessity) criteria.
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Notifies case management team and/or provider as needed when documentation and/or plan of care does not support continued stay.
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Is a resource to the Staff Registered Nurse (RN) in effective clinical management and/or discharge planning to meet goal length of stay.
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Initiates negotiation for extra-contractual benefits on a case/case basis. Documents pertinent information for Business Office.
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Obtains accurate and timely information from medical record, care coordinator and/or RN regarding clinical progress, care path variances and/or barriers to care (avoidable days) and documents in Milliman.
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Develops and maintains effective working relationships with all members of the health care team.
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Provides provider and care team ongoing education regarding utilization review/management.-
Reviews the medical record documentation and advises physician when additional documentation is required to support level of care or continued stay. Uses the Physician Documentation tip sheet/Milliman guidelines as resources for provider education.
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Informs/educates physician/staff when utilization management issues arise: i.e. reimbursement issues, benefits, criteria for continued hospitalization/medical necessity, effective resource utilization, and denial of benefits.
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Recognizes, understands, and communicates use of UR critical nursing decision making impacts the customers and hospital’s financial health.
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Maintains knowledge of regulatory guidelines and issues/performs the following functions:-
Important Message from Medicare.
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Medicare Outpatient Observation Notification.
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Condition Code 44.
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Discharge appeal via Livanta (QIO).
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Detailed Notice of Discharge.
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HINN 12-Non covered continued stay.
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HINN 1-Preadmission or admission denial.
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Advanced Beneficiary Notice.
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Waiver of Liability.
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Two Midnight Rule.
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BPCI Notification.
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Demonstrates behaviors that align with hospital core values such as:-
Uses descriptive language that does not negatively label patients/customers or their families and holds other team members accountable to do the same.
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Demonstrates commitment to excellence through ongoing education by attending and participating in staff meetings (minimum 50%), process improvement efforts, educational offerings from MCG, Optum, and payers.
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Essential Functions II-
Participates in mandatory in-services and/or CE programs as mandated by policies and procedures/external agencies and as directed by management.-
Completes annual Inter-rater reliability (IRR) competencies.
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Follows and understands the mission, vision, core values, Employee Standards of Behavior and company policies/procedures. -
Other duties as assigned.
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