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.