Manager Utilization Review​/RN

Overview

Oversees the evaluation of patients for appropriateness of admission type and setting, utilizing a combination of clinical information, screening criteria and third-party information across the DCH System. Serves as the primary educator for all DCH PA's, Case Managers, Social Workers, CDI personnel, Utilization Review Coordinators (URC), in the principles of utilization management and serves as a consultant for issues regarding regulations, compliance, payor specific criteria and the denial management process for the DCH System.

• Supervises utilization review professional and clerical employees.
• Establishes, manages, approves, and constantly evaluates staffing levels, performance, assignments, skills, learning needs and deployment of Utilization Review.
• Responsible to support and participate in DCH System strategies and efforts focused on improving length of stay (LOS) and reducing readmissions.
• Ensures orientation and training in Utilization Review for Utilization Review Staff.
• Manages the day to day operations for the DCH System Commercial Utilization Review function.
• Displays sound managerial judgment in all areas.
• Supervises and initiates or recommends personnel actions for Utilization Review staff members.
• Manages departmental budget and productivity standards.
• Interviews, selects, hires, and retains employees.
• Performs compliance requirements as outlined in the Employee Handbook.
• Approves payroll and is responsible for accurate payment of employees.
• Is knowledgeable of hospital mission, vision, and values, and performs in a manner to support them.
• Manages the performance of URC staff by providing feedback and direction.
• Informs staff of any insurance changes involving Inter Qual guidelines or in providing clinical reviews.
• Functions as a consultant to staff for solving challenging utilization issues throughout the DCH System.
• Analyzes each of the assigned medical records for the purpose of medical necessity and appropriate billing status.
• Collaborates with Business Office Personnel to identify correct insurance source, initial pre-certification information and provides clinical information as necessary to obtain authorization for payment.
• Manages utilization of Commercial observation process.
• Collaborates with the Case Manager to determine patient's appropriateness for acute hospital level of care.
• Evaluates patient's clinical course to verify patients continued need for acute hospital level of care.
• Provides third party payers with clinical information as needed to comply with payers' requirements for documentation of medical necessity.
• Negotiates a resolution of any DCH System disagreement over the need for acute hospital level of care with the insurer.
• Intervenes with appropriate parties regarding inappropriate admissions, delays in discharge and the over utilization of hospital resources.
• Intervenes with appropriate individuals regarding delays in service that may have an impact on the quality of patient care and/or length of stay.
• Refers appropriately to Performance Improvement and Risk Management for patient safety occurrences and sentinel events.
• Refers cases not meeting acute inpatient criteria to the physician advisor and assists with his/her review of the case.
• Gathers information for monthly statistical reports, special projects as assigned by the Corporate Director of Case Coordination.
• Assists in discharge planning by confirming patient's insurance benefits.
• Updates and documents in the computer system pertinent clinical information by utilizing screening criteria.
• Maintains records in a complete, detailed and orderly manner.
• Identifies potentially avoidable days per department policy.
• Establish appropriate staffing levels, assignments, and deployment of Utilization Review staff.
• Collaborates with Medical Records and patient Accommodations regarding patient billing status.
• Collaborates with the Financial Counselors to facilitate the Medicaid application process.
• Manages the delivery of the denial notification for the DCH Health System.
• Manages work list of BC/Commercial patients with Hospital acquired conditions/Never Events.
• Responsible to support and participate in department strategies and efforts focused on improving length of stay (LOS).
• Responsible to support and participate in department strategies and efforts focused on improving clinical documentation by physicians and staff.
• Manages the BC/BS's Concurrent Utilization Review program (CURP) for RMC, NMC, and FMC for the DCH System.
• Liaison between hospital & payers during concurrent and retrospective medical necessity audits for the DCH System.
• Manages continuation of benefits notices issued by Physician Advisor (i.e. pt. notification business office).
• Conducts retrospective medical record audits to verify appropriate administration of criteria and reports findings as directed.
• Conducts special focused reviews as directed.
• Collaborates with the Compliance Officer to assure accurate billing on cases with ambiguous orders.
• Supports departmental…