Utilization Review Clinical Specialist

Utilization management is the analysis of the necessity, appropriateness, and efficiency of medical services and procedures in the hospital setting. Utilization review is the assessment for medical necessity, both for admission to the hospital as well as continued stay. This function ensures that services are not only appropriate, but ensures that an authorization for services is obtained from payer, if required, and that documentation supports the care delivered in such a way that minimizes the risk of denials after discharge.

Community Health Systems, Inc. is one of the nation’s leading operators of general acute care hospitals. The organization’s affiliates own, operate or lease 89 hospitals in 16 states with approximately 15,000 licensed beds. Affiliated hospitals are dedicated to providing quality healthcare for local residents and contribute to the economic development of their communities. Based on the unique needs of each community served, these hospitals offer a wide range of diagnostic, medical and surgical services in inpatient and outpatient settings.

Summary:

Utilization management is the analysis of the necessity, appropriateness, and efficiency of medical services and procedures in the hospital setting. Utilization review is the assessment for medical necessity, both for admission to the hospital as well as continued stay. This function ensures that services are not only appropriate, but ensures that an authorization for services is obtained from payer, if required, and that documentation supports the care delivered in such a way that minimizes the risk of denials after discharge.

Essential Duties:

• Initial clinical assessments, continued stay assessments, and payer requested reviews are performed using evidence based criteria as designed, medical experience based problem solving skills, and following the established policies and regulations governing this process in order to either obtain authorization or establish medical necessity for hospitalized patients.
• Hold collaborative discussions with physicians on the medical staff, when needed, to obtain additional documentation in the record to support hospital medical necessity, discharge needs, or fulfill other payer requirements. These discussions are to help the UR Clinical Specialist understand the reason for admission, and better be able to request appropriate additional documentation from the physician(s).
• Escalates cases to the Utilization Review Manager and/or Physician Advisor if physicians are unable to provide any additional information to support the need for medically necessary hospital care.
• Documents all actions and activities in the case management software system used by the hospital. This documentation includes, but is not limited to, clinical reviews, escalations, avoidable days, payer contacts, authorization numbers, wDRG etc. Documentation may also be made in other systems as required based on hospital and/or corporate policies/procedures.
• In the event of concurrent denials, the UR Clinical Specialist reviews the denial and works with the physicians on the medical staff hospital’s to perform an internal secondary review to determine if there is need to downgrade the visit. The UR Clinical Specialist may assist coordinating a Peer to Peer discussion according to hospital and/or corporate direction. Results of the Peer to Peer are to be gathered from the physician presenting after the call and documented in the case management system by the UR Review Specialist.
• In the event a facility does not have an ED Case Manager present, the UR Clinical Specialist will
  collaborate with Emergency Room Physician/staff on ALL potential admissions during assigned hours to:
  a. Determine, if the patient is going to be admitted, and ensure appropriate documentation to validate the admission as an inpatient or to place in outpatient with observation services.
  b. Review medical record for appropriate indicators of the medical necessity for hospital care, and work with the healthcare team to ensure that medical necessity is clearly documented within the medical record.
  c. Educate physicians/healthcare team regarding appropriate documentation to support level of care using approved evidence based criteria as a guide.
  d. Document in the appropriate case management EMR the medical necessity information supporting the admission.
• UR Clinical Specialist communicates with the UR Coordinator and facility case manager(s) (i.e. licensed social workers,discharge planners, etc.) in –person, telephonically, and/or through the case management software to ensure effective collaboration between all disciplines managing a patient’s care.

Qualifications:

Required Education: Associates Degree in Nursing
Preferred Education: Bachelors Science Nursing or higher

Required Experience: At least 3 years previous nursing experience
Preferred Experience: 3 plus years Utilization review experience

Required License/Registration/Certification: Licensed Practical Nurse or Licensed Registered Nurse
Preferred License/Registration/Certification: ACM or CCM Certification

Computer Skills Required: Data entry skills; Demonstrable skills with Google Docs, Google Sheets, and email applications.

Physical Demands:

In order to successfully perform this job, with or without a reasonable accommodation, the following are outlined below:
1. The Employee is required to read, review, prepare and analyze written data and figures, using a PC or similar, and should possess visual acuity.

2. The Employee may be require to occasionally climb, push, stand, walk, reach, grasp, kneel, stoop, and/or perform repetitive motions.

3. The Employee is not substantially exposed to adverse environmental conditions and; therefore, job functions are typically performed under conditions such as those found within general office or administrative work. May be exposed to biohazardous material and pathogens.