Utilization Review Clinician

Job Summary:

Responsible for reviewing medical records, preparing clinical appeals (when appropriate) on medical necessity, length of stay, and authorization denials for hospitalized patients.  Utilization Review Manager will be responsible for compliance with CMS Conditions of Participation regarding Utilization Review and Discharge Planning and complies with hospital policies and procedures.  Knowledge of criteria for Medicare, Medicaid, HMO and private insurance coverage.  The Utilization Review Manager will practice improving quality through coordination of care impacting length of stay, minimizing cost, and ensuring optimum outcomes through

collaboration with CNO, Medical staff, and nursing staff.  

Supervisory Responsibility:

None.

Position Qualifications:

Current, valid, and active LPN - Licensed Practical Nurse, BSN - Registered Nurse or LSW- Social Worker license in the state of employment required.

Current BLS certification required

Key Responsibilities / Job Accountabilities:

• Responsible for filing appeals for hospital when appropriate.
• Responsible for evaluating and screening potential admissions to the facility when appropriate for impacting length of stay and minimizing cost.
• Knowledgeable of criteria for Medicare, Medicaid, HMO and private insurance coverage.
• Initiate ongoing communication with the patient and patient’s family in assess discharge needs.
• Communicate with physicians to ascertain their plans for a timely discharge.
• Document discharge planning.
• Knowledgeable of patient’s diagnosis and discharge needs to better assist patient in community, home or other.
• Fostering relationships with outside agencies for discharge planning.
• Knowledge of regulatory standards and compliance requirements.

Additional Skills / Qualifications:

• Possess strong clinical assessment and process skills.
• Strong written and oral communication skills.
• Ability to identify and resolve problems effectively and efficiently.
• Assertive and personable with the ability to balance the complex challenge of delivering quality, cost appropriate, and service-oriented outcomes.
• Execute various paperwork, like information files processing, and other daily administrative tasks.
• Maintain an efficient, organized work environment.
• Manages difficult customer situations; responds to requests for service and assistance.