Utilization Review Specialist
Company: CareFirst, Inc.Categories: Health Care, Nurse
Job description:PURPOSE: Reviews and certifies inpatient admissions for medical necessity, reviews inpatient days and applies criteria standards (Milliman and Robertson Health Care Management Guidelines and Modified AEP) and clinical judgement. Proactively assists with discharge planning, makes appropriate case management referrals and quality assurance referrals, and updates program and criteria to ensure that the quality care is rendered in the most cost effective and appropriate setting with high confidentiality for all lines of company business by CareFirstBCBS and subsidiaries’ health centers.
PRINCIPAL ACCOUNTABILITIES:
Under the general direction of the Utilization Management Supervisor the incumbent’s accountabilities include, but are not limited to, the following:
- 35% Conducts hospital concurrent review of inpatient stays for acute care criteria (may be conducted on site at the hospital). Determines appropriateness of admission and continued stay criteria according to Milliman and Robertson Health Care Management Guidelines, as well as Modified AEP and clinical judgement. Reviews case with CareFirstBCBS Physician Reviewer as appropriate.
- 20% Evaluates concurrent case files to advise physicians on alternative settings for care in order to manage health services and ensure cost effective care. Proactively identifies and assesses needs for discharge (e.g. home health care, prosthetic and ambulance services) Coordinates and communicates discharge plans with internal/external case managers, internal/external social workers, internal/external Care Management Staff. Generates appropriate authorizations.
- 10% Utilization Review Specialist communicates decisions to hospital Utilization Management Department and attending physician. Discusses the careplan, alternative discharge plans or other necessary clinical information. This information/decision is communicated to the appropriate hospital staff/attending physician in order to manage health services and ensure cost effective care.
- 10% Communicates caseload with Utilization Management Supervisor for length of stays greater than five days beyond Milliman and Robertson Health Care Management Guidelines/Modified AEP. Performs comprehensive analysis and develops action plan with the guidance of the Utilization Management Supervisor. Determines need for retrospective review.
- 5% Interacts professionally with internal departments and external physician community. Attends mandatory meetings and educational opportunities.
- 5% Presents and discusses all cases that may not meet the Milliman and Robertson Health Care Management Guidelines/Modified AEP criteria with a physician reviewer who then determines any denied days.
- 5% May assume the role of a preceptor for new orientees as requested.
- 5% Projects/committees for inter and intra-departmental needs.
- 5% Other duties as assigned.
SUPERVISORY RESPONSIBILITY: This position has no supervision over others.
SCOPE DATA: This position is responsible for maintaining approximately 150 - 160 acute care cases per month including: the integrity of the inpatient admissions, the number of days saved, and the communication and technical job process. Issues related to completion of Care Management standards: i.e. at least 90% concurrent review with a timely follow up; 90% Inter-rater score bi-monthly. Job requirements:
This position requires an active RN license with a minimum of five years of acute care experience: including inpatient care, hospice care, subacute and skilled care, and home health. Thorough knowledge of Utilization Review principles.
Abilities/Skills: Excellent analytical and problem solving skills; high level clinical competency is a necessity. Working knowledge of mainframe systems in order to access relevant information necessary for the review process. Must have excellent written and oral communication skills with the ability to refute and negotiate with internal and external contacts (professional and non-professional) on final review decisions and the ability to interpret contract benefits and managed care guidelines.
Preferred: Thorough knowledge of Milliman and Robertson Health Care Management Guidelines Criteria and Modified AEP. Understanding of managed care in the indemnity and HMO staff models is a plus. BSN with 1-2 years experience in a managed care environment. Knowledge of Medecisions data entry program.
PHYSICAL DEMANDS:
The physical demands described here are representative of those that must be met by an employee to perform the essential duties and responsibilities of the position successfully. Requirements may be modified to accommodate individuals with disabilities. Must have adequate transportation. The employee is primarily seated while performing the duties of the position. Walking within hospital for on-site, and standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. Computer is used daily for recordkeeping and organization. The employee must frequently talk and hear. Weights of up to 25 pounds are regularly lifted.