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Utilization Review Specialist-RN

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Company: Wellmont Bristol Regional Medical Center

Location: Kingsport, TN

Date Posted: May 29, 2014

Source: Wellmont Bristol Regional Medical Center

Analyzes patient records to determine legitimacy of admission, treatment and length of stay in health care facility ensuring to meet governmental and insurance company reimbursement policies. Analyzes commercial insurances based on facilities criteria to determine admission, ongoing admission compliance and length of stay approvals from payers. Communicates with Care Manager responsible for patient when patient fails to meet the admission or continued stay criteria, then works in concert with the Care Manager to set up the peer to peer and report these variances to the UR committee on a quarterly basis. Handles any concurrent denials that may arise, inputs all computer data into electronic payor source for approval and authorization. Determines patient review dates according to established criteria. May assist in planning and holding federally mandated quality assurance reviews in concert with the UR/Quality committee. Handles complex reviews; those that are at risk for denial and/or those requiring ...
Analyzes patient records to determine legitimacy of admission, treatment and length of stay in health care facility ensuring to meet governmental and insurance company reimbursement policies. Analyzes commercial insurances based on facilities criteria to determine admission, ongoing admission compliance and length of stay approvals from payers. Communicates with Care Manager responsible for patient when patient fails to meet the admission or continued stay criteria, then works in concert with the Care Manager to set up the peer to peer and report these variances to the UR committee on a quarterly basis. Handles any concurrent denials that may arise, inputs all computer data into electronic payor source for approval and authorization. Determines patient review dates according to established criteria. May assist in planning and holding federally mandated quality assurance reviews in concert with the UR/Quality committee. Handles complex reviews; those that are at risk for denial and/or those requiring a second level physician review. Communicates with physician, nursing, and ancillary staff regarding documentation of medical necessity and plan of care. Utilizes the nursing process to assess, plan, implement, and evaluate decisions regarding level of care. Provides ongoing education and updates for Case Management, Nursing, and medical staff regarding utilization issues and regulatory changes. Participates in data collection and analysis; provides recommendations for promotion of quality, cost-effective outcomes. Serves as Staff Support to Utilization Review Committee as requested.RN with at least 2 years of clinical experience in an acute care settingRN required. Certification in Case Management and/or Utilization Review preferred (CCM, ACM, or CPHM) , ,
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