Case Manager - Utilization Review Specialist - Remote

Case Manager - Utilization Review Specialist - Remote

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.

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.

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. 

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.