When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.
Contributes to the Hospital’s mission by supporting proper classification and a safe plan of care. This professional licensed position will have an impact on finance and growth by classifying patients’ status appropriately and supporting the workflow and care plan to ensure the delivery of high quality, safe patient care while maintaining an expected length of stay within budget. This role is critical to the denial management, utilization review, and discharge planning process and will support the evolution towards a system approach in this realm. This role functions in a high integrity manner and as a case management and utilization expert, collaborating interdepartmentally to educate and improve processes to appropriate classify patient status, which ultimately improves reimbursement. The Utilization Management Specialist will impact the patient experience and quality of care by daily rounding and working with the patient/family and provider to establish the best plan of care for discharge. This role will also cover in the absence of Director of Care Transitions
Job Description:
QUALIFICATIONS:
Education:
Required:
Bachelors of Science in Nursing
Preferred:
Master’s Degree in a health care field
5 year requirement: Masters Degree in Nursing or relevant field
Experience
Required
- At least five (5) years of experience as a Registered Nurse
- At least five (5) years of experience in inpatient case management and utilization review
- Experience in staff education in both the formal and non-formal setting presenting
- Certification in Case Management earned within one year of hire.
Preferred
- Demonstrated leadership experience
- Demonstrated ability to drive change resulting in achievement of hospital and department goals
- Ability to participate at system level meetings ensuring workflow design aligns with hospital operations resulting in achieving clinical, financial, and operational goals.
Other Skills/Knowledge
Required
- For safety and quality reasons, must be able to read, write and communicate effectively in English with patients, visitors, vendors, and fellow members of the hospital team.
- Computer skills
- Use of Leveling tools, including InterQual criteria
Preferred
LICENSES, REGISTRATIONS, CERTIFICATIONS
Required
- Current license to practice professional nursing from MA Board of Registration
Preferred
- Professional certification
POPULATION SPECIFIC REQUIREMENTS
Neonate, Infant, Children, Adolescent, Adult, and Geriatric
OTHER JOB REQUIREMENTS:
Professional Commitment Requirements: Keep abreast of developments in the field and/or licensure through continuing education, participation in professional organizations or a combination of both.
Schedule requirements: Contingent on the needs of the department.
Travel requirements: Local travel may be needed for training, education, and participation in system level meetings.
REPORTING RELATIONSHIPS:
- Reports to the Director, Care Transitions.
Direct Reports
JOB FUNCTIONS
Consistent with the WE CARE principles and inherent in a hospital environment, employees must be flexible in meeting patients’ and the Hospital’s needs. While the list below describes the primary functions of this job, all employees at Winchester Hospital need to recognize that an essential element of their job is the ability to respond to unanticipated and/or changing situations. This may result in assuming responsibilities or tasks which are not on this list.
Perform medical necessity surveillance, concurrent clinical reviews, patient status oversight and management, and coordination with financial team to ensure proper reimbursement.
The Utilization Management Specialist promotes the documentation of medical necessity and resource consumption during an inpatient hospitalization.
Provides concurrent and retrospective queries as supported by medical record documentation to improve the accuracy, integrity and quality of patient data, and improve the quality of the physician documentation within the body of the medical record. The candidate collaborates with all members of the case management department, unit managers, physicians and physician groups, staff nurses, coding staff and the multidisciplinary team. This role requires the ability to educate and present in both formal and informal venues for the purposes of hospital-wide compliance and continual performance improvement.
Medical Necessity/Utilization Reviewer
- Acts as Co-Chairperson of the hospital Utilization Review Committee
- Completes initial reviews of patient records upon admission and within 24–48 hours for medical necessity surveillance: Reviews all observation and Medicare one day stays for proper leveling, observation vs inpatient.
- Manages all work queues and follow up related to denials, appeals, resubmissions, audits, variances, and those created as a result of evolving work flows.
- Conducts follow-up reviews of patients every 2-3 days to ensure all elements of medical necessity and 2 MN Rule are documented
- Initiates the provision of beneficiary notices to patients or families
- Collaborates with the multi-disciplinary healthcare team regarding the patient’s plan of care to promote the best possible outcomes and patient/family experience upon discharge
- Works in partnership with an interdisciplinary team to foster collaboration, learning and accurate and complete medical record documentation.
- To assess the daily case management workflow and optimize the team’s efficiency, gathers census information, reviews admissions, reconciles admissions, transfers and discharges against census and conducts hand-offs regarding patients when appropriate
- Queries physicians regarding missing, unclear, or conflicting medical record documentation by requesting and obtaining additional documentation within the medical record when needed
- Interacts with team and providers to ensure correct level of care, status and accurate documentation to support patient stay. Works close with Physician Advisor and CDI staff.
- Proactively works with payer reviews- Performs concurrent reviews-. Reviews tests, procedures ordered for appropriateness/consultant delays. Coordinates second level peer to peer (physician) clinical reviews
- Educates physicians and key healthcare providers in both formal and informal settings regarding clinicaldocumentation improvement and the need for accurate and complete documentation in the medical record.
- Collaborates with case managers, nursing staff, coding team and inter-professional staff regarding interaction with physicians on documentation and to resolve physician queries prior to patient discharge.
- Participates in the analysis and trending of statistical data for specified patient populations to identify opportunities for improvement.
- Reviews external (i.e. PEPPER) and internal data (i.e. outliers) to trend, track and educate to improve outcomes.
- Consistently demonstrate a working knowledge of regulatory standards and the ability to function that positions
the hospital as a high integrity, continually compliant organization.
- Preparation and presentation clinical documentation monitoring/trending reports for review with physicians and hospital leadership.
- Educates members of the patient care team regarding specific documentation needs and reporting and reimbursement issues identified through daily and retrospective documentation reviews and aggregate data analysis.
- Instructs staff on best practices to ensure accurate documentation in the medical record.
- Maintains and reports clinical documentation improvement results in a clear and concise manner to the medical, clinical, and management staff.
- Applies diplomacy and professionalism when interacting with physicians and clinical staff; especially when addressing missing or conflicting medical record information
- Acts as a consultant to providers, management, administration and billing staff with regard to documentation, coding, and reimbursement and compliance matters.
- Investigates, evaluates and identifies opportunities for improvement and recognizes their relative significance in the overall system.
- Maintains confidentiality of all customer/hospital information.
- Demonstrates flexibility in the face of changing work environment, adjusting work schedule