Utilization Management RN- Denials

Summary

GENERAL SUMMARY:

Conducts day-to-day activities for the clinical, financial and utilization coordination of the patient’s hospital experience. Proactively consults with the interdisciplinary team which includes, but is not limited to, hospital patient care staff, physicians, patient support and family to ensure the patient’s hospital stay meets medical necessity and insurance authorizations are obtained in order to facilitate the patient’s and hospitals financial well-being.

PRINCIPAL JOB FUNCTIONS:

1. *Commits to the mission, vision, beliefs and consistently demonstrates our core values.

2. *Performs utilization review activities, including concurrent and retrospective reviews as required.

3. *Determines the medical necessity of request by performing first level reviews, using approved evidence based guidelines/criteria.

4. *Collaborates with the patient’s provider and other healthcare team members in managing the patient’s length of stay and determining the continuing medical necessity of continued stays.

5. *Refers cases to reviewing physician when the treatment request does not meet criteria per appropriate algorithm.

6. *Participates in concurrent and retrospective denials and appeals process by researching issues surrounding the denial, participating in all levels of the appeal and process follow-up.

7. *Serves as an internal and external resource regarding appropriate level of care; admission status/classification; Medicare/Medicaid rules, regulations, and policies; 3rd party and managed care contracts; discharge planning; and length of stay.

8. Ensures appropriate resource utilization relevant to the financial, regulatory and clinical aspects of care; proposes alternative treatment to ensure a cost effective and efficient plan of care.

9. *Maintains awareness of financial reimbursement methodology, utilization management, payer/reimbursement practices and regulations and participates in resource stewardship.

10. *Promotes quality improvement initiatives and health care outcomes based on currently accepted clinical practice guidelines and total quality improvement initiatives.

11. Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise.

12. Participates in meetings, committees and department projects as assigned.

13. Performs other related projects and duties as assigned.

(Essential Job functions are marked with an asterisk “*”. Refer to the Job Description Guide for the definition of essential and non-essential job functions.) Attach Addendum for positions with slightly different roles or work-specific differences as needed.

REQUIRED KNOWLEDGE, SKILLS AND ABILITIES:

1. Maintains clinical competency as required for the unit including but not limited to age-specific competencies relative to patient’s growth and developmental needs, annual skill competency verification and mandatory education and competencies.

2. Knowledge of governmental and third party payer regulations and requirements related to patient hospitalization and acute rehabilitation admission, stay and discharge activities, i.e., CMS, CARF, FIM (TM).

3. Knowledge of computer hardware equipment and software applications relevant to work functions.

4. Skill in conflict diffusion and resolution.

5. Ability to communicate effectively both verbally and in writing.

6. Ability to perform crucial conversations with desired outcomes.

7. Ability to establish and maintain effective working relationships with all levels of personnel and medical staff.

8. Ability to problem solve and engage independent critical thinking skills.

9. Ability to maintain confidentiality relevant to sensitive information.

10. Ability to prioritize work demands and work with minimal supervision.

11. Ability to maintain regular and punctual attendance.

ADDITIONAL JOB FUNCTIONS:

In addition to the principal job functions contained on the primary job descriptions, the following duties are also required in the department noted above.

1. Responsible for performing clinical review and analysis in support of the denials team in managing patient medical denials through the request of documentation and assistance in preparing cases for presentation and evaluation. Collaborates with utilization management, case management, revenue cycle, and the physician advisor. Partners with the physician advisor to develop and defend clinical positions on denied cases

2. Reviews all denial accounts for categorization, level of appeal, and special requirements for initiating appeals evaluating medical necessity and level of care.

3. Reviews and compiles required denial documentation and submits in a timely manner to ensure compliance with required timelines.

4. Supports the appeal process by ensuring that proper documentation is provided to support appeals of unauthorized inpatient days or days denied for lack of documentation.

5. Manages new denials. Reviews hospital records for medical necessity and routes to the appropriate teams or personnel. Identifies gaps in clinical documentation and initiates appropriate clinical or operational interventions. Screens new denials and assigns preliminary denial reasons. Analyzes denial trends and determines root causes from a clinical perspective, validating or challenging payer denial rationale

6. Tracks and documents tasks to assist in preparing and following up on pending cases. Maintains documentation of clinical determinations and appeal activities, ensuring accuracy and compliance with regulatory and payer requirements.

7. Tracks and monitors concurrent and retrospective cases within electronic records.

8. Assists in auditing for administrative and medical necessity denials and identify opportunities for improvement in clinical documentation and utilization practices. Enters and schedules Peer to Peer reviews when necessary.

9. Assists with paperwork and follow-up of self-denied cases, and Condition Code W2s.

10. Assists in gathering data for performance of retrospective denials. Analyzes clinical denial data to identify trends, patterns, and opportunities for process improvement, and provides recommendations to clinical and operational leadership.

EDUCATION AND EXPERIENCE:

Two (2) years of utilization management experience with strong knowledge of the denials process and payor behaviors is preferred.

EDUCATION AND EXPERIENCE:

Current Registered Nurse licensure from the State of Nebraska or approved compact state of residence as defined by the Nebraska Nurse Practice Act. Two (2) years recent clinical experience required. Prior care coordination and/or utilization management experience preferred.

OTHER CREDENTIALS / CERTIFICATIONS:

Basic Life Support (BLS) certification required. Bryan Health recognizes American Heart Association (for healthcare professionals), American Red Cross (for healthcare professionals) and the Military Training Network.

PHYSICAL REQUIREMENTS:

(Physical Requirements are based on federal criteria and assigned by Human Resources upon review of the Principal Job Functions.)

(DOT) – Characterized as sedentary work requiring exertion up to 10 pounds of force occasionally and/or a negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects, including the human body.