Essential Duties & Responsibilities
The essential functions include, but are not limited to the following:
- Coordinate and facilitate correct identification of patient status.
- Facilitates optimal reimbursement through accurate certification and denial processes, including complete chart documentation ensuring that the appropriate admission status is ordered.
- Coordinate and integrate UM functions.
- Conducts concurrent and retrospective reviews based on Xsolis AI capabilities with usage of Client approved Care Level Score decision matrixes.
- Refers cases for secondary review when appropriate.
- Supports the medical necessity denial and appeal process.
- Collaborate with all members of the healthcare team, both internal and external.
- Refers and consults with the multidisciplinary team to promote appropriate communication in the absence of definitive documentation and/or review criteria to support hospital stay.
- Communicate with third party payers regarding patient clinical progress.
- Assists the UM team in educating providers on trends found in medical necessity statuses, authorization, and communication from third-party payers.
- Participate in clinical performance improvement activities to achieve set goals.
- Demonstrate positive and professional written, verbal, and nonverbal communication skills.
- Apply advanced critical thinking and conflict resolution skills using creative approaches.
- The responsibilities listed are a general overview of the position and additional duties may be assigned.
Minimum Qualifications (Knowledge, Skills, and Abilities)
Education:
- Minimum Licensed Practical Nurse, A.A.S. in Nursing, or BSN
Experience:
- Minimum 3-5 years of experience in an acute care hospital setting or equivalent health care experience in utilization management and case management
- Knowledge of Medicare rules and regulatory standards
- Excellent interpersonal communication, problem-solving, and conflict resolution skills.
- Computer skills in word processing, database management, and spreadsheet desirable.
- Knowledge in areas of: Medicare and Medicaid UM regulations, Medicare Inpatient Only List, RAC, QIO, MAC, and Denial Management.
Supervisory Responsibilities
This role does not have any direct reports and is a single contributor role.
Working Environment and Travel Requirements
Work is typically in a normal office administrative environment involving minimal exposure to physical risks. Position requires little to moderate physical activity. Mostly sedentary work exerting up to 10 pounds of force occasionally or a negligible amount of force to lift, carry, push, pull, or otherwise move objects. Work involves sitting most of the time, but may involve walking or standing for brief periods of time. No significant stooping is usually required.
