Case Manager - Utilization Review Specialist - Remote
Full-Time Position
You must reside in one of these states to be eligible for position:
Arkansas California Kentucky
Massachusetts Nevada New Mexico
Oregon Utah Tennessee
Texas Wyoming
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.
EDUCATION/TRAINING & EXPERIENCE:
Current state-issued RN license. Knowledge in areas such as InterQual Level of
Care Criteria and Milliman & Robertson Criteria as well as knowledge of third
party payer regulations related to utilization and quality review is also
preferred.
KEY JOB RESPONSIBILITIES:
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: Analyzes insurance, governmental,
and accrediting agency standards to determine criteria concerning admissions,
treatment, and length of stay of patients.
Reviews application for patient admission and approves admission or refers
case to facility utilization review committee for review and course of action
when case fails to meet admission standards.
Compares inpatient medical records to established criteria and confers with
medical and nursing personnel and other professional staff to determine
legitimacy of treatment and length of stay.
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 to ensure timely resolution of issues or appeals.
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 in resolving
denial and appeal questions.
Ensure proper documentation of all denials into billing systems to include
tracking outcome for reporting to appropriate parties
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.
EXPERIENCE / SKILLS:
Significant experience in the healthcare field is required including a
minimum of five years as a clinical nurse in an acute care setting. In
addition, having at least five to seven years of experience in case
management, discharge planning, and/or utilization review is preferred.
Knowledge of regulatory and payer requirements for Case Management
Activities.
Ability to critically evaluate and make decisions about whether discharge
planning for highly difficult cases
Ability to use pre-existing criteria sets and/or clinical evidence from an
existing library of clinical references and/or regulatory arguments to
support one’s own clinical appeals arguments
Maintains confidentiality of patient data and medical records in compliance
with HIPAA regulations.
Ability to read, evaluate, and abstract important information from
handwritten patient medical records.
Excellent oral and technical writing and typing skills.
Demonstrates flexibility with a willingness to learn and adapt to changes in
regulations and task-related priorities.
Ability to successfully work independently and to adapt quickly to changing
priorities and regulations. Excellent oral and technical writing skills and
the Ability to maintain confidentiality according to HIPAA regulations is
required.
Other duties as assigned.