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Description:I. Basic Purpose: The Utilization Review Specialist is responsible for concurrent and retrospective medical record review activities on all inpatients. Serves as a clinical resource person for the health care team when determining appropriateness of admission and continued stays. Gathers required clinical information and report to insurance company's patient's progress and plan to receive authorization for continued stay. Communicates information to appropriate staff members to assist in discharge planning efforts. II. Major Duties and Responsibilities:
Complies with established corporate and departmental policies, procedures, objectives, quality assurance methods, and safety codes. Demonstrates compliance with licensing, regulatory and accrediting agency provisions as required.
Consistently demonstrates appropriate and professional communication behavior toward patients, customers, and coworkers. Cooperates with Management and peers to promote an environment of teamwork and collaboration.
The Utilization Review Specialist has the responsibility to carry out the established departmental policies and procedures. Support the policies and procedures, goals and objectives of the Case Management Services Department and the organization, including but not limited to the risk management programs, safety, environment and infection control standards.
Demonstrates appropriate and professional communication behavior toward patients, customers, and coworkers. Cooperates with Management and peers in order to facilitate an environment of teamwork and collaboration.
The review specialist has the responsibility to be knowledgeable of the standards of practice for Case Management, Utilization Management and review. Must be knowledgeable of approved acute care criteria with the application of InterQual and Milliman & Robertson (M & R) criteria as utilized by the payer source.
Assess and evaluate patients for a designated segment on admission and continued stay for acute care criteria, by application of approved utilization acuity criteria. Communicates with appropriate parties regarding problems identified with the patient meeting acute care criteria immediately. Documents findings
Collaborates with Utilization Management Coordinator when variables are identified that may indicate inappropriate use of inpatient resources. Follows department process for management of utilization.
Communicates required clinical information with insurance companies to obtain authorization for proposed services (i.e.: admission, continued stay, transfer, home health, or other services). Communicate approvals or denials to Case Manager.
Proactively monitors patient activity, and identifies and resolves delays and obstacles to discharge. Monitors length of stay and documents avoidable days.
Interface with onsite reviewers as needed to assure information they need to make authorization decisions is readily available.
Consult with physicians to discuss patient status and any questions that may be unanswered by clinical documentation.
Support and coach clinical documentation efforts ensuring that documentation accurately reflects severity of illness and intensity of care criteria.
Assists with issuing denial letters as directed by Utilization Management Coordinator and following established departmental process standards.
Reviews and coordinates responses to denials; coordinates response or action on patient stays that have been issued a pending status; assists with the response to the PRO or other insurance companies.
Demonstrates good communication skills and positive guest relations with patients, families, physicians, and all other associates within the Health System.
Demonstrates a commitment to the organization and the Case Management Department. Reacts to change productively. Actively participates in performance improvement activities.
Enhances professional growth and development through participation in educational programs, current literature, in-services, meetings and workshops.
Maintains annual mandatory education requirements specific to position as mandated by Martin Health System.
Performs all other duties as assigned or requested.
III. Minimum Requirements (experience, training, and education): To effectively fulfill this position, candidate must meet the following requirements:
Candidate should have a minimum of 3 years clinical experience, current working knowledge utilization management, and performance improvement and reimbursement issues.
Recommend Case Management Certification, additional course work in utilization or other applicable certification attained within 24 months of accepting the position as Utilization Review Specialist.
Current/Active State of Florida RN or LPN License required - Primary source online verification required directly from State of Florida Licensing database.
Bachelor's degree preferred. Certified Case Manager or related utilization certification preferred.
Strong analytical, organizational and time management and computer skills. Excellent interpersonal communication and negotiation skills. Ability to work independently and exercise sound judgment in interactions with physicians, payers, patients and families. Must be knowledgeable of application of utilization management principles and a working knowledge of InterQual, Milliman & Robertson (M & R) criteria.The policy of Cleveland Clinic and its system hospitals (Cleveland Clinic) is to provide equal opportunity to all of our employees and applicants for employment in our tobacco free and drug free environment. All offers of employment are followed by testing for controlled substance and nicotine. Job offers will be rescinded for candidates for employment who test positive for nicotine. Candidates for employment who are impacted by Cleveland Clinic’s Smoking Policy will be permitted to reapply for open positions after 90 days. Decisions concerning employment, transfers and promotions are made upon the basis of the best qualified candidate without regard to color, race, religion, national origin, age, sex, sexual orientation, marital status, ancestry, status as a disabled or Vietnam era veteran or any other characteristic protected by law. Information provided on this application may be shared with any Cleveland Clinic facility.Cleveland Clinic is pleased to be an equal employment employer: Women/Minorities/Veterans/Individuals with Disabilities
