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Utilization Review Specialist

Methodist Health System Omaha, NE
  • Purpose of Job
    • Performs utilization review functions, manages the denial process and participates in the discharge planning process.
  • Job Requirements
    • Education
      • Successful completion of annual mandatory education requirements.
      • Graduate of an accredited nursing program required.

    • Experience
      • A minimum of two years of clinical experience to gain medical surgical knowledge to be able to apply criteria to determine appropriate level of care.

    • License/Certifications
      • Current valid license, valid compact multi-state license, or a temporary permit while awaiting licensure required for work state.
        • Registered Nurse License

    • Skills/Knowledge/Abilities
      • Interpersonal skills necessary in order to review and communicate effectively with external and internal customers.
      • Computer knowledge.
  • Physical Requirements
    • Weight Demands
      • Light Work - Exerting up to 20 pounds of force.

    • Physical Activity
      • Not necessary for the position (0%):
        • Climbing
        • Crawling
        • Kneeling
      • Occasionally Performed (1%-33%):
        • Balancing
        • Carrying
        • Crouching
        • Distinguish colors
        • Grasping
        • Lifting
        • Pulling/Pushing
        • Standing
        • Stooping/bending
        • Twisting
        • Walking
      • Frequently Performed (34%-66%):
        • Fingering/Touching
        • Keyboarding/typing
        • Reaching
        • Repetitive Motions
        • Sitting
        • Speaking/talking
      • Constantly Performed (67%-100%):
        • Hearing
        • Seeing/Visual

    • Job Hazards
      • Not Related:
        • Chemical agents (Toxic, Corrosive, Flammable, Latex)
        • Physical hazards (noise, temperature, lighting, wet floors, outdoors, sharps) (more than ordinary office environment)
        • Equipment/Machinery/Tools
        • Explosives (pressurized gas)
        • Electrical Shock/Static
        • Radiation Alpha, Beta and Gamma (particles such as X-ray, Cat Scan, Gamma Knife, etc)
        • Radiation Non-Ionizing (Ultraviolet, visible light, infrared and microwaves that causes injuries to tissue or thermal or photochemical means)
        • Mechanical moving parts/vibrations
      • Rare (1-33%): 
        • Biological agents (primary air born and blood born viruses) (Jobs with Patient contact) (BBF)
  • Essential Job Functions
    • Essential Functions I

      • Performs utilization review functions in compliance with department guidelines.
        • Performs admission and concurrent reviews for medical necessity on all cases utilizing Milliman Criteria.
        • Documents clinical reviews (admission, continued stay, secondary) in Milliman using appropriate criteria level (ambulatory, observation, inpatient, acute, intermediate, ICU, NICU).
        • Selects RRG criteria in Milliman for screening for majority of reviews.

        • Provides timely medical information to payers and receives authorization.
        • Verifies authorization of services and communicates information to case management/nursing team.

        • Collaborates with other members of the UR team to ensure UR functions completed each day.

        • Directs UR Financial Clearance Specialists to verify payer source as needed.

        • Manages the accuracy of patient status (inpatient/observation) and level of care. (leveling)

        • Documents accurately in UM documentation avoidable days, denials, & peer to peer reviews.

        • Refers self-pay patients to MASH if not already done.

        • Appropriately refers cases to Physician Advisor for review when severity of illness and intensity of service do not meet ordered admission status and/or payer does not concur with hospital identified level of care or status.
        • Follows recommended workflow and documentation guidelines for department. Uses Case Management work list to direct priorities for the day using sorting function.
        • Makes decisions based on evidence based practice, research, and UR nurse higher order critical thinking skills and experience.

      • Follows Payer Aligned Processes
        • Develops/maintains positive working relationship with payer nurse reviewer.

        • Participates in payer meetings.

        • Provides feedback for improvement in processes related to specific payers.

        • Accesses payer website to research preauthorization requirements.

        • Submits preauthorization information to payer for medications, cardiac event monitors.
        • Identifies and communicates to department manager opportunities to address during contract negotiations.

        • Provides information for inclusion in Payer Information spreadsheet.
        • Maintains knowledge of Payer requirements regarding length of stay for observation and transition to Inpatient
        • Maintains knowledge of Payer requirements for peer to peer process, Skilled nursing facility authorization, & LTAC reviews.

      • Manages the denial process for Inpatients, Observation patients, and continued stay reviews.
        • Coordinates the denial/appeal process. Interacts with the attending physician and Physician Advisor to review and address adverse reimbursement decisions of managed care organizations.

        • Upon direction of Physician Advisor, delivers denial letter to the patient, legal guardian, or health care power of attorney for all payer sources.

        • Communicates to Business Office and Clinical Denials and Appeals pertinent information regarding denials of payment and/or levels of care.

        • Documents actions taken and outcome(s) in Cerner Case Management tool, payer information.

        • Issues Medicare Outpatient Observation Notification (MOON) letter following Condition Code 44 process.

        • Completes Medicare discharge appeal process, providing timely information to QIO. Checks QIO website for case progression and outcome. Notifies other team members of appeal and outcome.

      • Participates in discharge planning process.
        • Is knowledgeable about the medical plan of care.

        • Attends and actively participates in interdisciplinary rounds. Communicates pertinent information regarding; covered/approved days, DRG LOS (diagnosis-related group and length of stay) projections, criteria for continued stay, patient benefits, and if patient is not meeting SI/IS (medical necessity) criteria.
        • Notifies case management team and/or provider as needed when documentation and/or plan of care does not support continued stay.
        • Is a resource to the Staff Registered Nurse (RN) in effective clinical management and/or discharge planning to meet goal length of stay.
        • Initiates negotiation for extra-contractual benefits on a case/case basis. Documents pertinent information for Business Office.

        • Obtains accurate and timely information from medical record, care coordinator and/or RN regarding clinical progress, care path variances and/or barriers to care (avoidable days) and documents in Milliman.
        • Develops and maintains effective working relationships with all members of the health care team.

      • Provides provider and care team ongoing education regarding utilization review/management.
        • Reviews the medical record documentation and advises physician when additional documentation is required to support level of care or continued stay. Uses the Physician Documentation tip sheet/Milliman guidelines as resources for provider education.
        • Informs/educates physician/staff when utilization management issues arise: i.e. reimbursement issues, benefits, criteria for continued hospitalization/medical necessity, effective resource utilization, and denial of benefits.
        • Recognizes, understands, and communicates use of UR critical nursing decision making impacts the customers and hospital’s financial health.

      • Maintains knowledge of regulatory guidelines and issues/performs the following functions:
        • Important Message from Medicare.

        • Medicare Outpatient Observation Notification.

        • Condition Code 44.

        • Discharge appeal via Livanta (QIO).
        • Detailed Notice of Discharge.
        • HINN 12-Non covered continued stay.
        • HINN 1-Preadmission or admission denial.
        • Advanced Beneficiary Notice.

        • Waiver of Liability.
        • Two Midnight Rule.
        • BPCI Notification.

      • Demonstrates behaviors that align with hospital core values such as:
        • Uses descriptive language that does not negatively label patients/customers or their families and holds other team members accountable to do the same.
        • Demonstrates commitment to excellence through ongoing education by attending and participating in staff meetings (minimum 50%), process improvement efforts, educational offerings from MCG, Optum, and payers.

    • Essential Functions II

      • Participates in mandatory in-services and/or CE programs as mandated by policies and procedures/external agencies and as directed by management.
        • Completes annual Inter-rater reliability (IRR) competencies.

      • Follows and understands the mission, vision, core values, Employee Standards of Behavior and company policies/procedures.

      • Other duties as assigned.

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Date Posted June 30, 2022
Date Closes August 29, 2022
Requisition 21671
Located In Omaha, NE
SOC Category 00-0000.00

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