Provides coordination of benefits and related services to specific patient groups to assure the highest quality of care is provided in a cost-effective manner. Works with insurers the PRO for Medicare and Medicaid billing physicians and a variety of other decision-makers for medical appropriateness.
- Associate's degree or equivalent experience
- 1-3 years experience RN license - NH or other Compact State
- UR Certified within 1 year of hire
- Reviews all admissions and provides clinical information to third party payors as required by contracts.
- Maintains a working knowledge of nationally accepted criteria sets (Milliman and Interqual) for inpatient vs outpatient status.
- Attends complex discharge rounds on Wednesday when scheduled.
- Links Utilization Management with Case Management .
- Reviews notices of potential denials and respond appropriately; ie facilitate Physician to Physician appeals when appropriate and assist with construction of appeal letters.
- Tracks denial information for reporting to Quarterly UR Committee.
- Provides ongoing education to the medical; nursing and hospital staff on current utilization practices and documentation requirements.
- Collaborates with Pre-cert and Patient Accounts staff as needed to ensure proper payment.
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