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Utilization Review Specialist
Location:
Waukegan, IL
Description:
Analyzes patient records to determine legitimacy of admission, treatment, and length of stay in the health-care facility to comply with government and insurance company reimbursement policies: Analyzes insurance, governmental, and accrediting agency standards to determine criteria concerning admissions, treatment, and length of stay of patients. Responsibilities : Reviews application for patient admission and approves admission or refers case to facility utilization review committee for review and course of action when case fails to meet admission standards. Compares inpatient medical records to established criteria and confers with medical and nursing personnel and other professional staff to determine legitimacy of treatment and length of stay. Abstracts data from records and maintains statistics. Determines patient review dates according to established diagnostic criteria. May assist review committee in planning and holding federally mandated quality assurance reviews. May supervise and coordinate activities of utilization review staff. Research clinical records, appropriate insurance regulations and history of claim to determine next step. Monitor day to day compliance of appeal decision time frames and collaborate with other departments to ensure timely resolution of issues or appeals. Review clinical and medical records for completeness and determine administrative or clinical appeal. Assign reviews to physician advisors and medical directors for those requiring medical necessity reviews. Coordinate first and second level appeals. Consults with managers on problem cases and interfaces with case managers, clinical supervisors, account managers and other personnel in resolving denial and appeal questions. Ensure proper documentation of all denials into billing systems to include tracking outcome for reporting to appropriate parties. Manage first level appeals to ensure timely submissions. Monitor volume of appeals in order to engage additional resources when needed. Form professional relationships with payer appeals and utilization departments. Enter all data related to appeals and case reviews into a database. Prepare and present information on appeals to applicable committees and personnel as requested. Demonstrate ability to draft professional letter by incorporating supporting documents, policies and statutes. Requirements : Current IL issued RN license Graduate from an accredited nursing school.
Company:
AHS Vista
Posted:
November 15 on ApplicantPro, TalentPlusHire
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