Utilization Review RN/Documentation Specialist - (Full-Time) - OSS HEALTH : Job Details

Qualifications And EducationEducation:

• Graduate of a professional school of nursing with licensure, or eligible for licensure as an RN in the Commonwealth of Pennsylvania.

Qualifications:

• At least 3 years of experience with Interqual Level of Care Criteria, MCG, or available software program and knowledge of local and national coverage determinations preferred.
• Recent work experience in the hospital or insurance industry preferred (within the past 3 years).
• Familiarity with procedure status indicators and inpatient-only listings preferred.
• Must have proficient computer skills, as well as effective communication skills, both verbal and written.
• Knowledge of, but not limited to, current coding guidelines and methodologies, MSDRG, APR-DRG, HCCs; ICD-10-CM/PCS coding guidelines and conventions.

Essential Duties And ResponsibilitiesAccess to Care

• Conducts inpatient pre-admission and admission review for Medicare and Medicaid beneficiaries, as well as private insurance members and self-pay patients based on CMS guidelines.
• Uses Interqual Level of Care Criteria, MCG, or available software program to screen for inpatient level of care or observation services based on physician documentation, H&P, treatment plan, potential risks, and basis for expectation of a two-night stay.
• Understands and applies federal law regarding the use of Hospital Initiated Notice of Non-Coverage (HINN), Medicare Outpatient Observation Notice (MOON), and Advance Beneficiary Notice (ABN) for all applicable patients.
• Ensures that commercial payers are immediately advised if their members do not qualify for acute level of care according to the criteria used.
• Keeps current on all regulatory changes that affect delivery or reimbursement of acute care services. Uses knowledge of national and local coverage determinations to appropriately advise physicians.
• Consistently identifies and records information on any progression-of-care/patient flow barriers.
• Consults with medical staff, care team, and case managers as necessary to resolve immediate progression-of-care barriers through appropriate administrative and medical channels.
• Engages care team colleagues in collaborative problem-solving regarding appropriate utilization of resources.
• Promotes the use of best practice guidelines at point-of-entry and notes any deviances.
• Recognizes and responds appropriately to patient safety/risk factors.

Continuing Stay

• Actively participates in daily huddles, rounds and patient care conferences. Consults with hospitalist/nurse/physician to maintain knowledge about intensity of services and the progression of care.
• Identifies potentially wasteful or misused resources and recommends alternatives if appropriate by analyzing clinical protocols.
• Maintains appropriate documentation on each patient to include specific information of all resource utilization activities.
• Identifies and records episodes of preventable delays or avoidable delays due to failure of progression-of-care processes.
• Educates members of the patient's care team on the appropriate access to and use of various levels of care.
• Represents utilization management at various committees, professional organizations, and physician groups as needed.
• Promotes use of evidence-based protocols and/or order sets to influence high-quality and cost-effective care.
• Promotes medical documentation that accurately reflects findings and interventions, presence of complications or comorbidities, quality and safety indicators, and patient's need for continuing stay.
• Confers with attending physician and APP if medically unnecessary inpatient treatment is contemplated. Issues the appropriate HINN if not resolved.

Transition

• Confirms patient's readiness for discharge based on medical necessity for continued acute care stay.
• Consults with the patient's nurse to confirm agreement by the patient and the care team concerning the discharge plan.
• Opens a communication channel with post-acute services arranged through the resource center to stay current on finding and arranging services to initiate discharge plan.
• Serves as a resource person to physicians, case managers, physician offices, and billing office for coverage and compliance issues.
• Works closely with decision support personnel to review resource utilization data and trends to identify outliers who may benefit from real-time coaching to improve outcomes.

Supervisory ResponsibilitiesNo direct reports.Language SkillsMust be proficient in the English language, both verbally and written, to communicate effectively with patients, co-workers, physicians, vendors, and the general public.PHYSICAL DEMANDSLong periods of sitting. May require bending and stooping. Fine and gross motor skills and manual dexterity to operate keyboard and other equipment. Frequently works under pressure to meet deadlines or deal with problem situations. Must be able to respond quickly and effectively to an emergency.The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.WORK ENVIRONMENTClimate controlled environment with occasional periods of being outside. Exposed to blood borne pathogens, odorous chemicals and specimens, toxic chemicals, electrical and mechanical hazards, confused or combative patients, bio-contaminated waste, and unpleasant elements. Subject to stressful situations, long or irregular hours.