Utilization Review Specialist Jobs

ST. CHARLES HEALTH SYSTEM

JOB DESCRIPTION

TITLE: Utilization Review Specialist

REPORTS TO POSITION: Manager, Utilization Review

DEPARTMENT: Revenue Cycle

DATE LAST REVIEWED: March 9, 2023

OUR VISION: Creating America’s healthiest community, together

OUR MISSION: In the spirit of love and compassion, better health, better care, better value

OUR VALUES: Accountability, Caring and Teamwork

DEPARTMENTAL SUMMARY: The Utilization Review Department provides many services to our multi-hospital organization including: Support to physicians and clinical staff in determining whether all aspects of a patient’s care, is medically necessary at every level and appropriately delivered. The Utilization Review Department also acts to ensure compliance with the Medicare Conditions of Participation and capture of appropriate reimbursement for the health system.

POSITION OVERVIEW The Utilization Management Specialist at St. Charles Health System completes clinical reviews of hospital admissions for medical necessity utilizing InterQual criteria, to ensure that revenue is fully and accurately captured for hospital stays. This position works closely with physicians, nursing staff, insurance companies, patient registration, and patient financial services to accurately document medical necessity and admitting status for each admission. This position does not directly supervise any other caregivers.

ESSENTIAL FUNCTIONS AND DUTIES:

Performs clinical chart reviews for appropriateness and medical necessity of admissions, continued stays, and supportive services to promote quality care and full and accurate capture of revenue.

Assures conformity to the federal and state government health care program requirements, the internal hospital utilization review process, and any third party payer utilization review processes or managed care process.

Reviews and completes clinical reviews for medical necessity of hospital stays and refers to second level review when necessary.

Communicates with the attending physician or with nursing staff, when needed, to address issues of medical necessity and appropriate level of care and to discuss order changes. Delivers appropriate Medicare forms to patients when required (e.g. Code 44, Code W2, and Hospital Issued Notices of Non Coverage).

Communicates with insurance companies regarding the medical necessity of the admission and provides clinical documentation and reviews to insurance companies as requested for purposes of ongoing authorization of hospital stays.

Keeps patient registration and patient financial services informed of any changes in admission status, working towards accurate capture of admission status prior to the time the initial billing is sent.

Continually assesses clinical services for appropriateness for continued stay.

Works collaboratively with RN Case Managers and/or Social Services caregivers in order to communicate high priority cases in a timely manner.

Serves as a resource to and actively provides education for physicians related to Medicare and third party payor billing requirements related to correct admission status and documentation to support medical necessity.

Participates with the Utilization Review Committee.

Identifies and reports quality of care issues through the EMS system or immediately if indicated, to risk management.

Participates in medical necessity denials and appeals processes. Ensures prompt and accurate follow up to ensure resolution and timely billing.

Participates in multidisciplinary team meetings on appropriate medical units.

Documents actions taken in the patient financial record and clinical review criteria application.

Participates in tracking of departmental quality measures by abstracting and reporting UM data.

Supports the vision, mission and values of the organization in all respects.

Supports Value Improvement Practice (VIP- Lean) principles of continuous improvement with energy and enthusiasm, functioning as a champion of change.

Provides and maintains a safe environment for caregivers, patients and guests.

Conducts all activities with the highest standards of professionalism and confidentiality. Complies with all applicable laws, regulations, policies and procedures, supporting the organization’s corporate integrity efforts by acting in an ethical and appropriate manner, reporting known or suspected violation of applicable rules, and cooperating fully with all organizational investigations and proceedings.

Delivers customer service and/or patient care in a manner that promotes goodwill, is timely, efficient and accurate.

May perform additional duties of similar complexity within the organization, as required or assigned.

EDUCATION

Required: Associate's degree or higher in Health Information Management or degree that meets the requirements to obtain a RHIT.

Preferred: N/A

LICENSURE/CERTIFICATION/REGISTRATION

Required: Current RHIT

EXPERIENCE

Required: 2 years’ experience in similar hospital related position with utilization experience preferred

Preferred: N/A

PERSONAL PROTECTIVE EQUIPMENT

Must be able to wear appropriate Personal Protective Equipment (PPE) required to perform the job safely.

ADDITIONAL POSITION INFORMATION

General:

Must have excellent communication skills and ability to interact with a diverse population and professionally represent St. Charles Health System.

Ability to effectively interact and communicate with all levels within SCHS and external customers/clients/potential employees.

Strong team working and collaborative skills.

Ability to multi-task and work independently

Attention to detail.

Excellent organizational skills, written and oral communication and customer service skills, particularly in dealing with stressful personal interactions.

Strong analytical, problem solving and decision making skills.

Intermediate to advanced proficiency in Microsoft applications (Word, Excel and Access), database management, and document preparation

PHYSICAL REQUIREMENTS:

Continually (75% or more): Use of clear and audible speaking voice and the ability to hear normal speech level.

Frequently (50%): Sitting, standing, walking, lifting 1-10 pounds, keyboard operation.

Occasionally (25%): Bending, climbing stairs, reaching overhead, carrying/pushing or pulling 1-10 pounds, grasping/squeezing.

Rarely (10%): Stooping/kneeling/crouching, lifting, carrying, pushing or pulling 11-15 pounds, operation of a motor vehicle.

Never (0%): Climbing ladder/step-stool, lifting/carrying/pushing or pulling 25-50 pounds, ability to hear whispered speech level.

Exposure to Elemental Factors

Never (0%): Heat, cold, wet/slippery area, noise, dust, vibration, chemical solution, uneven surface.

Blood-Borne Pathogen (BBP) Exposure Category

No Risk for Exposure to BBP

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