Baton Rouge General
JOB PURPOSE OR MISSION
Responsible for the revenue integrity of the medical record by ensuring appropriate clinical level of care. Conduct concurrent medical record review for medical necessity and level of care using nationally recognized acute care indicators and criteria as approved by medical staff, TJC, CMS, and other state agencies. Prospectively or concurrently determines the appropriateness of inpatient or observation services following review of relevant medical documentation, medical guidelines and insurance benefits and communicates information to payers in accordance with contractual obligations. Serves as a resource to the physicians and provides education and information on resource utilization, national and local coverage determinations. Collaborates with Care Coordinator in the development and implementation of the plan of care, serving as a primary resource to the Utilization Review Nurse I (LPN), and ensures prompt notification of any denials to the appropriate Care Coordinator, Denials & Appeals Coordinator, and UR Supervisor.
PERFORMANCE CRITERIA CRITERIA A: Everyday Excellence Values – Employee demonstrates Everyday Excellence values in the day-to-day performance of the job.
Demonstrates courtesy and caring to each other, patients and their families, physicians, and the community.
Takes initiative in living our Everyday Excellence values and vital signs.
Takes initiative in identifying customer needs before the customer asks.
Participates in teamwork willingly and with enthusiasm.
Demonstrates respect for the dignity and privacy needs of customers through personal action and attention to the environment of care.
Keeps customers informed, answers customer questions and anticipates information needs of customers
CRITERIA B: Corporate Compliance – Employee demonstrates commitment to the Code of Conduct, Conflict of Interest Guidelines, and the GHS Corporate Compliance Guidelines.
Practice’s diligence in fulfilling the regulatory and legal requirements of the position and department.
Maintains accurate and reliable patient/organizational records.
Maintains professional relationships with appropriate officials; communicates honestly and completely; behaves in a fair and nondiscriminatory manner in all professional contacts.
CRITERIA C: Personal Achievement – Employee demonstrates initiative in achieving work goals and meeting personal objectives.
Uses accepted procedures and practices to complete assignments. Uses creative and proactive solutions to achieve objectives even when workload and demands are high.
Adheres to high moral principles of honesty, loyalty, sincerity, and fairness.
Upholds the ethical standards of the organization.
CRITERIA D: Performance Improvement – Employee actively participates in Performance Improvement activities quality improvement standards in his/her job performance.
Optimizes talents, skills, and abilities in achieving excellence in meeting and exceeding customer expectations.
Initiates or redesigns to continuously improve work processes.
Contributes ideas and suggestions to improve approaches to work processes.
Willingly participates in organization and/or department quality initiatives.
CRITERIA E: Cost Management – Employee demonstrates effective cost management practices.
Effectively manages time and resources.
Makes conscious effort to effectively utilize the resources of the organization – material, human, and financial.
Consistently looks for and uses resources saving processes.
CRITERIA F: Patient & Employee Safety – Employee actively participates in and demonstrates effective patient and employee safety practices.
Employee effectively communicates, demonstrates, coordinates and emphasizes patient and employee safety.
Employee proactively reports errors, potential errors, injuries or potential injuries.
Employee demonstrates departmental specific patient and employee safety standards at all times.
Employee demonstrates the use of proper safety techniques, equipment and devices and follows safety policies, procedures, and plans.
JOB FUNCTIONS
Provides front-end revenue cycle through a pre-certification and access to care strategy.
Collaborate with the access management team to ensure accurate and complete clinical and payer information.
Review OR schedule prior to patient surgery to influence appropriate utilization of resources and appropriate level of care determination.
Reviews H&P and admitting orders of all direct and transfer patient requests prior to patient’s arrival to ensure compliance with CMS guidelines regarding appropriateness of level of care.
Performs admission reviews on all assigned patients to determine appropriateness of admission and level of care based on medical necessity using clinical guidelines.
Educates members of the patient’s healthcare team on the appropriate access to and use of various levels of care.
Promote use of evidence-based protocols and/or order sets to influence high quality and cost-effective care.
Understands and applies federal law regarding the use of Hospital Initiated Notice of Non-Coverage (HINN), Ambulatory Benefit Notice (ABN), Important Message from Medicare (IMM), Medicare Outpatient Observation Notice (MOON), and Condition Code 44 (CC44).
Monitors and facilitates continued stay requirements and expectations of payers and the hospital.
Promote medical documentation that accurately reflects intensity of services, quality and safety indicators and patient’s need to continuing stay.
Pro-actively participate as a member of the interdisciplinary clinical team to confirm appropriateness of the treatment plan relative to the patient’s preference, reason for admission, and availability of resources.
Establish and maintain effective professional working relationships with patients, families, interdisciplinary team members, payers, and external case managers.
Identify potentially unnecessary services and care delivery settings and recommend alternatives if appropriate by analyzing clinical protocols.
Consults with medical advisor as necessary to resolve progression-of-care barriers through appropriate administrative and medical channels.
Identifies and refers complex cases to appropriate Care Coordinator and/or supervisor.
Participates in Complex Outlier Patient Evaluations (COPE), as needed by leadership, to discuss any payer concerns or issues.
Works with physicians to ensure appropriate documentation for CMS 20-day certification requirements.
Maximizes appropriate resource utilization and medical necessity by:
Communicates appropriate clinical information to payers.
Helps to ensure that physician documentation supports medical necessity.
Communicates and collaborates with the Care Coordinator to assist with appropriate interventions to avoid denial of payment.
Assists in arranging peer to peer conferences to avoid denial of payment
Assists in the denials and appeals process.
Communicates with payers regarding discharges by sending discharge notifications as appropriate.
Closes out each case once date of service authorization is complete.
Participates in quality improvement activities as stewards for resource utilization as it pertains to medical necessity and level of care.
Identify and record episodes of preventable delays or avoidable days due to failure of the progression of care process.
Reports sentinel evens and quality of care issues to the Director of Case Management.
Participates in performance improvement activities as needed. Which include regular UR team meetings and may be asked to provide case reviews for internal process improvement initiatives.
May be asked to represent Utilization Management at various committees, professional organizations, and physician groups.
Serves as a resource person to physicians, case managers, physician offices, and billing office for coverage and compliance issues.
Documents in the care management UR software specific patient information received regarding level of care, authorizations, and approved/denied days.
Keeps current on all regulatory changes that affect delivery or reimbursement of acute care services.
Assists in developing and revising policies to support utilization management activities, including criteria and guidelines for appropriate use of services, clinical practice guidelines and treatment guidelines.
Serves as a primary resource to the Utilization Review Nurse I (LPN) by:
Assists with cases that are not meeting medical necessity for admission and/or continued stay reviews.
Communicates with external payers, physicians, and/or Care Coordinator when peer to peer conferences are needed.
Ensures appropriate order is written by the physician.
Assists with cases that have been issues denials and/or rejections.
Performs all other duties as assigned.
EXPERIENCE REQUIREMENTS
Expert knowledge of InterQual Level of Care Criteria or Milliman Care Guidelines and knowledge of local and national coverage determinations.
Recent work experience in the hospital or insurance industry.
EDUCATIONAL REQUIREMENTS
Current Louisiana RN licensure
SPECIAL SKILLS, LICENSE AND KNOWLEDGE REQUIREMENTS
Demonstrates knowledge of human behavior, socioeconomic factors in disease and illness, behavior patterns of the physically and mentally ill patient.
Demonstrates outstanding communication skills and can establish constructive relationships with patients, families, payers, and hospital associates.
Demonstrates advanced knowledge of regulatory and payer requirements as it pertains to level of care, medical documentation, and medical necessity.
Works well under pressure of time and shifting priorities.
ACM or CCM certification preferred.
HIPAA REQUIREMENTS Maintains knowledge of and adherence to all applicable HIPAA regulations appropriate to the job position, including but not limited to: Medical records without limitation of both paper and electronic, patient demographics, lab and radiology results, patient information related to surgery or appointment schedules, information related to patient location, religious beliefs and/or public health records, medical records related to quality/data, patient financial information and/or 3rd party billing, patient-related complaints, research information, employee health records and employee prescriptions.
SAFETY REQUIREMENTS Maintains knowledge of and adherence to all applicable safety practices appropriate to the job position, including but not limited to: Incident reporting, PPE, exposure control plans, hand washing, environment of care, patient identification.
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PERFORMANCE CRITERIA CRITERIA A: Everyday Excellence Values – Employee demonstrates Everyday Excellence values in the day-to-day performance of the job.
Demonstrates courtesy and caring to each other, patients and their families, physicians, and the community.
Takes initiative in living our Everyday Excellence values and vital signs.
Takes initiative in identifying customer needs before the customer asks.
Participates in teamwork willingly and with enthusiasm.
Demonstrates respect for the dignity and privacy needs of customers through personal action and attention to the environment of care.
Keeps customers informed, answers customer questions and anticipates information needs of customers
CRITERIA B: Corporate Compliance – Employee demonstrates commitment to the Code of Conduct, Conflict of Interest Guidelines, and the GHS Corporate Compliance Guidelines.
Practice’s diligence in fulfilling the regulatory and legal requirements of the position and department.
Maintains accurate and reliable patient/organizational records.
Maintains professional relationships with appropriate officials; communicates honestly and completely; behaves in a fair and nondiscriminatory manner in all professional contacts.
CRITERIA C: Personal Achievement – Employee demonstrates initiative in achieving work goals and meeting personal objectives.
Uses accepted procedures and practices to complete assignments. Uses creative and proactive solutions to achieve objectives even when workload and demands are high.
Adheres to high moral principles of honesty, loyalty, sincerity, and fairness.
Upholds the ethical standards of the organization.
CRITERIA D: Performance Improvement – Employee actively participates in Performance Improvement activities quality improvement standards in his/her job performance.
Optimizes talents, skills, and abilities in achieving excellence in meeting and exceeding customer expectations.
Initiates or redesigns to continuously improve work processes.
Contributes ideas and suggestions to improve approaches to work processes.
Willingly participates in organization and/or department quality initiatives.
CRITERIA E: Cost Management – Employee demonstrates effective cost management practices.
Effectively manages time and resources.
Makes conscious effort to effectively utilize the resources of the organization – material, human, and financial.
Consistently looks for and uses resources saving processes.
CRITERIA F: Patient & Employee Safety – Employee actively participates in and demonstrates effective patient and employee safety practices.
Employee effectively communicates, demonstrates, coordinates and emphasizes patient and employee safety.
Employee proactively reports errors, potential errors, injuries or potential injuries.
Employee demonstrates departmental specific patient and employee safety standards at all times.
Employee demonstrates the use of proper safety techniques, equipment and devices and follows safety policies, procedures, and plans.
JOB FUNCTIONS
Provides front-end revenue cycle through a pre-certification and access to care strategy.
Collaborate with the access management team to ensure accurate and complete clinical and payer information.
Review OR schedule prior to patient surgery to influence appropriate utilization of resources and appropriate level of care determination.
Reviews H&P and admitting orders of all direct and transfer patient requests prior to patient’s arrival to ensure compliance with CMS guidelines regarding appropriateness of level of care.
Performs admission reviews on all assigned patients to determine appropriateness of admission and level of care based on medical necessity using clinical guidelines.
Educates members of the patient’s healthcare team on the appropriate access to and use of various levels of care.
Promote use of evidence-based protocols and/or order sets to influence high quality and cost-effective care.
Understands and applies federal law regarding the use of Hospital Initiated Notice of Non-Coverage (HINN), Ambulatory Benefit Notice (ABN), Important Message from Medicare (IMM), Medicare Outpatient Observation Notice (MOON), and Condition Code 44 (CC44).
Monitors and facilitates continued stay requirements and expectations of payers and the hospital.
Promote medical documentation that accurately reflects intensity of services, quality and safety indicators and patient’s need to continuing stay.
Pro-actively participate as a member of the interdisciplinary clinical team to confirm appropriateness of the treatment plan relative to the patient’s preference, reason for admission, and availability of resources.
Establish and maintain effective professional working relationships with patients, families, interdisciplinary team members, payers, and external case managers.
Identify potentially unnecessary services and care delivery settings and recommend alternatives if appropriate by analyzing clinical protocols.
Consults with medical advisor as necessary to resolve progression-of-care barriers through appropriate administrative and medical channels.
Identifies and refers complex cases to appropriate Care Coordinator and/or supervisor.
Participates in Complex Outlier Patient Evaluations (COPE), as needed by leadership, to discuss any payer concerns or issues.
Works with physicians to ensure appropriate documentation for CMS 20-day certification requirements.
Maximizes appropriate resource utilization and medical necessity by:
Communicates appropriate clinical information to payers.
Helps to ensure that physician documentation supports medical necessity.
Communicates and collaborates with the Care Coordinator to assist with appropriate interventions to avoid denial of payment.
Assists in arranging peer to peer conferences to avoid denial of payment
Assists in the denials and appeals process.
Communicates with payers regarding discharges by sending discharge notifications as appropriate.
Closes out each case once date of service authorization is complete.
Participates in quality improvement activities as stewards for resource utilization as it pertains to medical necessity and level of care.
Identify and record episodes of preventable delays or avoidable days due to failure of the progression of care process.
Reports sentinel evens and quality of care issues to the Director of Case Management.
Participates in performance improvement activities as needed. Which include regular UR team meetings and may be asked to provide case reviews for internal process improvement initiatives.
May be asked to represent Utilization Management at various committees, professional organizations, and physician groups.
Serves as a resource person to physicians, case managers, physician offices, and billing office for coverage and compliance issues.
Documents in the care management UR software specific patient information received regarding level of care, authorizations, and approved/denied days.
Keeps current on all regulatory changes that affect delivery or reimbursement of acute care services.
Assists in developing and revising policies to support utilization management activities, including criteria and guidelines for appropriate use of services, clinical practice guidelines and treatment guidelines.
Serves as a primary resource to the Utilization Review Nurse I (LPN) by:
Assists with cases that are not meeting medical necessity for admission and/or continued stay reviews.
Communicates with external payers, physicians, and/or Care Coordinator when peer to peer conferences are needed.
Ensures appropriate order is written by the physician.
Assists with cases that have been issues denials and/or rejections.
Performs all other duties as assigned.
EXPERIENCE REQUIREMENTS
Expert knowledge of InterQual Level of Care Criteria or Milliman Care Guidelines and knowledge of local and national coverage determinations.
Recent work experience in the hospital or insurance industry.
EDUCATIONAL REQUIREMENTS
Current Louisiana RN licensure
SPECIAL SKILLS, LICENSE AND KNOWLEDGE REQUIREMENTS
Demonstrates knowledge of human behavior, socioeconomic factors in disease and illness, behavior patterns of the physically and mentally ill patient.
Demonstrates outstanding communication skills and can establish constructive relationships with patients, families, payers, and hospital associates.
Demonstrates advanced knowledge of regulatory and payer requirements as it pertains to level of care, medical documentation, and medical necessity.
Works well under pressure of time and shifting priorities.
ACM or CCM certification preferred.
HIPAA REQUIREMENTS Maintains knowledge of and adherence to all applicable HIPAA regulations appropriate to the job position, including but not limited to: Medical records without limitation of both paper and electronic, patient demographics, lab and radiology results, patient information related to surgery or appointment schedules, information related to patient location, religious beliefs and/or public health records, medical records related to quality/data, patient financial information and/or 3rd party billing, patient-related complaints, research information, employee health records and employee prescriptions.
SAFETY REQUIREMENTS Maintains knowledge of and adherence to all applicable safety practices appropriate to the job position, including but not limited to: Incident reporting, PPE, exposure control plans, hand washing, environment of care, patient identification.
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