Utilization Review Specialist - Casual

Why work for Nebraska Methodist Health System?
At Nebraska Methodist Health System, we focus on providing exceptional care to the communities we serve and people we employ. We call it The Meaning of Care – a culture that has and will continue to set us apart. It’s helping families grow by making each delivery special, conveying a difficult diagnosis with a compassionate touch, going above and beyond for a patient’s needs, or giving a high five when a patient beats a disease or conquers a personal health challenge. We offer competitive pay, excellent benefits and a great work environment where all employees are valued! Most importantly, our employees are part of a team that makes a real difference in the communities we live and work in.

Job Summary:

Responsibilities:

Essential Functions

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.

Schedule:

Casual

Job Description:

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)

About Methodist:

Nebraska Methodist Health System is made up of four hospitals in Nebraska and southwest Iowa, more than 30 clinic locations, a nursing and allied health college, and a medical supply distributorship and central laundry facility. From the day Methodist Hospital was chartered in 1891, service to our communities has been a top priority. Financial assistance, health education, outreach to our diverse communities and populations, and other community benefit activities have always been central to our mission.

Nebraska Methodist Health System is an Affirmative Action/Equal Opportunity Employer and does not discriminate on the basis of race, color, religion, sex, age, national origin, disability, veteran status, sexual orientation, gender identity, or any other classification protected by Federal, state or local law.