Utilization Review Specialist - Traverse City, United States - Munson Healthcare

Description

• We're northern Michigan's largest healthcare system and we are deeply rooted in the communities we serve. That means that our patients are often our family, friends and neighbors - and it's special to be able to care for them. And as one of the top healthcare systems to work for in Michigan by Forbes (American's Best Employers by State 2022), we're committed to your ongoing growth and development.
• After work, you'll find things to do in every season - beaches, outdoor recreation, unique restaurants, world-class wineries, arts and entertainment.

• Reviews available documentation to assess all admissions for appropriate status and services according to patient condition and diagnosis.
• Applies standard guidelines to determine appropriateness for inpatient level of care or observation services based on documented condition plan of treatment and care.
• Supports physician decision-making by coaching on appropriateness of inpatient or observation status.
• Confers with admitting physician if documentation does not support hospital level of care to offer alternatives.
• 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.
• Understands and applies federal law regarding the use of Hospital Initiated Notice of Non-Coverage (HINN) and Ambulatory Benefit Notice (ABN).
• Monitors insurer compliance with contractual obligations.
• Maintains proficiency in the use of electronic review applications including CERMe and EMR and enters information correctly, consistently and timely.
• Maintains proficiency in the use of hospital information systems to access information and record data.

• 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.
• Consults with case manager and/or physician advisor as necessary to resolve progression-of-care barriers through appropriate administrative and medical channels.
• Identify potentially unnecessary services and care delivery settings and recommend alternatives when appropriate.
• Collaborates with community physicians and hospitalists to influence transition from one level of care to another.
• Notifies insurers and third party administrators of clinical review information.
• Maintains documentation on each patient to include specific criteria that support appropriate level of care and continued stay. Performs status changes as necessary
• Refers cases to the Physician Advisor when treatment plan documentation does not support acute level of care. Monitors timeliness of PA response.
• Identify and record episodes of preventable delays or avoidable days due to failure of progression-of-care processes.
• Promote physicians' use of evidence based protocols and/or order sets to influence high quality and cost effective care.

• Collaborate with clinical team to confirm benefit eligibility for post-acute services.
• Apply Interqual/Milliman discharge screens to assess patient's readiness for a lower level of care.
• Updates all involved parties regarding potential, threatened or actual denials due to lack of medical necessity or barriers to the progression of care.
• Participates in reviewing 30-day Readmissions as directed by program manager.
• Reviews request for direct admissions and transfers for appropriate level of care.
• Coordinates with ED Case Manager to recommend alternate placement from the ED when patients do not qualify for Outpatient Observation or Inpatient status

• Serves as a resource person to physicians, case managers, physician offices, and billing office for coverage and compliance issues.
• 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.
• Encourage healthcare team members in collaborative problem solving regarding appropriate use of resources.
• 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.
• Recognizes and responds appropriately to risk factors.
• 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.
• May represent Utilization Management on various committees, professional organizations, physician or and community groups
• Establish and maintain effective professional working relationships with patients, families, interdisciplinary team members, payers and external case managers

• Our dynamic work environment includes many opportunities for growth and development
• Be a part of a team that nurtures a culture of caring every day
• Our employees work in positive, supportive, and compassionate environments built on our organizational values.

• 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.
• 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)
• 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 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

• Competitive salaries
• Full benefits, paid holidays, and paid time off (up to 19 days your first year)
• Tuition reimbursement and ongoing educational opportunities
• Retirement savings plan with employer match and personal consulting
• Wellness plans, an employee assistance program and employee discounts