The Concurrent Utilization Management (UM) Nurse is responsible for completing pre-admission, initial, concurrent and/or retrospective reviews of inpatient hospitalization services and for the determination of medical appropriateness and medical necessity for a variety of patient cohorts using evidence-based clinical guidelines and/or nationally recognized criteria. The UM RN will use their clinical findings from their reviews to inform the care team of level of care recommendations, identify continued stay variances, relay and attempt to overcome authorization issues, generate estimated expected dates of discharge, as well as highlight any provider documentation concerns.
DUTIES & ESSENTIAL JOB FUNCTIONS
Identify the functions or tasks that employees in the job perform. The essential functions should state the purpose of the work and the results to be accomplished, rather than how the function is performed. Of the tasks listed , what percentage of time is devoted to each? The more time employees spend on a function, the more likely it is that the function is essential. Generally, include those functions that account for 10% or more of the work, i.e., key items that contribute significantly to the achievement of the job. The functions should add up to 100%.
%
of time
Essential Function (Yes/No)
Key Responsibilities
(To be completed by Supervisor)
50
Y
Utilization Review
Utilizes and applies nationally recognized criteria and UCSF protocols in the utilization management process, while using clinical assessment and judgement skills to determine appropriateness and timeliness of medical care. Identifying and anticipate medically necessary services required across the continuum. Document finding in the EMR and other required databases/systems and ensure that all pertinent information is sent to the payor to ensure all services are authorized.
Maintains awareness and assists in the interdisciplinary collaboration with third party payor criteria and other regulatory requirements and regulations; advises physicians and other members of the health care team, as needed, to facilitate compliance, and ultimately receive authorization and reimbursement. Maintains awareness and knowledge of all applicable programs, including CCS, MediCal, Medicare, VA, Workers Compensation, HMOs, PPO and other insurances, coordinating the required communication to demonstrate the medical necessity of care, and facilitate authorization for hospital care.
Completes initial, admission and concurrent reviews to facilitate appropriate level of care identification and authorizations. Reviews medical record documentation to assess and determine appropriateness of medical necessity for admission, continued hospitalization, and appropriate level of care. Identifies concerns related to medical necessity, timeliness of care delivery, and plan of treatment, discussing as appropriate with physician attending, interdisciplinary care team and/or Physician Advisor as necessary.
Serves as the designated clinical contact for external insurance reviewers regarding authorizations and continued stay inquiries.
For non-admitted patients, assess clinical need for admission and appropriate admission type. Relay findings to the care team to ensure the most appropriate admission type is chosen and refer case to Case Management, Social Work and/or physician advisor depending on the identified needs.
Generate and report an estimated date of discharge based on national benchmarks on clinical documentation.
25
Y
Government Utilization Management
Apply the CMS Medicare Two-Midnight Rule, the Medicare IP Only list criteria and other guidelines to all Medicare Inpatient admissions that stay less than three days. Initiate CMS Code 44process as defined in the Utilization Review Plan for any Medicare admission that does not appear it will meet CMS guidelines.
Complete daily clinical reviews, using a nationally recognize review tool, for all admitted inpatient days for patients with Medi-Cal, MediCaid or no insurance. Care dates of service that do not meet criteria will be referred for secondary review by our internal or contracted external physician advisors.
Medi-Cal admissions that do not meet inpatient standards will be reviewed for DHCS Medi-Cal Administrative Day criteria as part of the TAR Free program. Care days that do not meet Inpatient or Administrative Day criteria will be flagged for non-payment.
5
Y
Governmental Audits
Participate in governmental (DHCS, RAC, MAC, QIO and CMS) audits. This includes completing chart reviews and identifying possible financial risks; evaluating and appealing audit results, as warranted, and educating the care team on any identified thematic findings.
15
Y
Commercial Insured Utilization Management Denials
Assess all commercially insured patient payor medical necessity denials for possible appeal or downgrade by utilizing clinical knowledge, evidence-based practice literature, nationally recognized practice standards of care, a complete review of the patient’s chart, payor contract and/or payor denial patterns.
Based on clinical assessment the Concurrent UM RN will attempt to resolve the denial proactively and/or coordinate a peer-to-peer discussion to attempt to overturn pre-bill denials that appear to meet clinical criteria. Documents all efforts and assessment within the organization EMR.
Identify payor practice patterns that would negatively impact financial revenue. Share findings with Utilization Management Leadership, Patient Financial Services, Admission and/or the Contracting Departments.
5
Y
Additional Utilization Management Responsibilities
Supports Departmental Performance Improvement efforts and the hospital Utilization Management Committee through focused reviews and/or special studies which may be hospital-wide, services/physician/payor specific.
Staff will be cross trained to at least one additional Utilization Management area of focus and may be assigned to cover those areas upon department leadership discretion.
0
0
0
0
0
0
0%
(To update total %, enter the amount of time in whole numbers (without the % symbol - e.g., 15, 20) then highlight the total sum (e.g., 1%) at the bottom of the column and press F9. The total sum should add up to 100%.)
Required qualifications:
Working knowledge of medical terminology, anatomy and physiology, diagnosis, surgical procedures, basic disease processess and basic knowledge of medical records coding standards. Skilled in the operation of computers including strong working knowledge of Microsoft Outlook ®, Microsoft Word ®, and Microsoft Excel ®.Knowledge of billing practices,adequacy of documentation, and ability to conduct research on issues at hand, as well as formulate recommendations based on findings;capable of providing in-service education to health care providers in regard to this topic; awareness of licencing and accrediation standards. Solid organizational skills and ability to multi-task with demanding timeframes.Knowledge and experience with MCG and/or InterQual criteria. Advanced interpersonal and communication for written and verbal skills necessary to gather and exchange data (both internally and externally) with members of the health care team and/or external reviewer; prioritization and organize work to meet changing priorities. Ability to use discretion and maintain confidentiality.Possess strong analytical ability required to gather data, use clinical judgement to apply predetermined criteria, or uses independent clinical judgement when no predetermined criteria exist to identify problems, facilitate resolution, recommend corrective action, and report results effectively.Self-directed with the ability to prioritize and adapt to a high-volume changing environment. Independent clinical judgement in reviewing records to determine status of patients stay, if proper procedures have been followed, seriousness of incidents, and participate in focused reviews, special projects and identify opportunities for improvement.Assertive and creative in problem solving abilities while functioning as an active team member.Strong customer service skills to coordinate service delivery including attention to members/customers, sensitivity to concerns, proactive identification and resolution of issues to promote positive outcomes for members.
Ability to type minimum 45 wpm using a QWERTY keyboard.
Ability to perform all job responsibilities independently without direct supervision in offsite or onsite work environments while still maintaining expected productivities.
Demonstrates ability to take direction from multiple team members across multiple departments.
Preferred qualifications:
Licenses/Certifications:
