- Initial clinical assessments, continued stays assessments, and payer requested reviews are performed using evidence based criteria as designed, medical experience based problem solving skills, and following the established policies and regulations governing this process in order to either obtain authorization or establish medical necessity for hospitalized patients.
- Hold collaborative discussions with physicians on the medical staff, when needed, to obtain additional documentation in the record to support hospital medical necessity, discharge needs, or fulfill other payer requirements. These discussions are to help the UR Clinical Specialist understand the reason for admission, and better be able to request appropriate additional documentation from the physician(s).
- Escalates cases to the Utilization Review Manager and/or Physician Advisor if physicians are unable to provide any additional information to support the need for medically necessary hospital care.
- Documents all actions and activities in the case management software system used by the hospital. This documentation includes, but is not limited to, clinical reviews, escalations, avoidable days, payer contacts, authorization numbers, wDRG etc. Documentation may also be made in other systems as required based on hospital and/or corporate policies/procedures.
- In the event of concurrent denials, the UR Clinical Specialist reviews the denial and works with the physicians on the medical staff hospital's to perform an internal secondary review to determine if there is need to downgrade the visit. The UR Clinical Specialist may assist coordinating a Peer to Peer discussion according to hospital and/or corporate direction. Results of the Peer to Peer are to be gathered from the physician presenting after the call and documented in the case management system by the UR Review Specialist.
- In the event a facility does not have an ED Case Manager present, the UR Clinical Specialist will collaborate with Emergency Room Physician/staff on ALL potential admissions during assigned hours to: O Determine, if the patient is going to be admitted, and ensure appropriate documentation to validate the admission as an inpatient or to place in outpatient with observation services.
- UR Clinical Specialist communicates with the UR Coordinator and facility case manager(s) (i.e. licensed social workers, discharge planners, etc.) in -person, telephonically, and/or through the case management software to ensure effective collaboration between all disciplines managing a patient's care.
- Perform other duties as assigned.
- Active FL. RN License
- 5 years acute care experience and 2 years Case Manager (CM) Experience
- CM experience preferred at an acute care hospital
- Discharge Planning Knowledge
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Description
UR Clinical Specialist Denials- RNTGH Brooksville & Spring Hill are a 244-bed Health System Joint Commission, Accredited Chest Pain Center, and Primary Stroke Center.
TGH Brooksville care services include a surgery program, a dedicated orthopedic joint replacement center and two cardiac catheterization labs. The joint replacement program offers robotic-arm assisted partial knee and total hip replacement surgeries.TGH Brooksville is designated as an Accredited Chest Pain Center with PCI (Percutaneous Coronary Intervention) TGH Spring Hill features a Level II neonatal intensive care unit (NICU).
TGH Spring Hill also offers care for women during pregnancy and continuing through birth, postpartum care and beyond.TGH Crystal River Wound Care Center offers care for non-healing wounds and hyperbaric medicine programs that use technology to help heal wounds.
Other care services include general surgery, ENT (ear, nose and throat), plastic surgery, urology and therapy rehab centers including outpatient physical, occupational and speech therapies.
This position is at the Spring Hill location processing denials.O Review medical record for appropriate indicators of the medical necessity for hospital care, and work with the healthcare team to ensure that medical necessity is clearly documented within the medical record.
O Educate physicians/healthcare team regarding appropriate documentation to support level of care using approved evidence based criteria as a guide.
O Document in the appropriate case management EMR the medical necessity information supporting the admission.
