Lexington Medical Center
Utilization Review Specialist - Lexington Medical Center
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Utilization Review Specialist
role at
Lexington Medical Center .
Part Time — Day Shift (7:00 AM – 3:00 PM).
Job Summary Performs admission and concurrent stay medical record review to determine appropriateness of admission, continued stay, and setting. Follows the patient throughout hospitalization, collaborating with attending physician and other health care providers. Communicates with third‑party payors to obtain authorization. Contributes to throughput and length of stay. Assists with denial management. Reviews physician medical record documentation and consults with physicians regarding completeness.
Minimum Qualifications
Minimum Education: ADN, Diploma Nursing Degree, or Bachelor of Science in Nursing.
Minimum Years of Experience: 3 years in an acute care hospital setting.
Required Licensure: Registered Nurse currently licensed in South Carolina.
No substitutable education or experience.
Essential Functions
Work in a cooperative manner, fostering favorable relations between employees, patients, families, visitors, fellow employees, and medical staff.
Exhibit commitment and pride by positively speaking of Lexington Medical Center, the department, employees, and guests.
Contribute to teamwork and create harmonious, effective, and positive working relationships with others.
Respect, understand, and respond with sensitivity to employees and guests.
Resolve conflicts and solve problems calmly, seeking solutions or referring to authority when appropriate, and aiming to deliver more than expected.
Exhibit telephone courtesy:
Answer promptly with name and department.
Speak with a pleasant tone while focusing on the caller.
Transfer calls correctly and promptly.
Attend to calls on hold in a timely manner.
Maintain confidentiality:
Disregard gossip.
Use discretion when discussing patient or LMC-related information.
Utilize the service recovery process to resolve complaints (GIFT).
Demonstrate competence in providing duties within the role.
Demonstrate competence to provide developmentally appropriate planning/review for patients of all age groups.
Identify need for professional growth and seek appropriate development opportunities, attaining a minimum of 15 hours of continuing education annually.
Serve as a role model for other members of the health care team.
Demonstrate receptiveness to change and flexibility in meeting department needs.
Assist in orientation and training of staff.
Perform admission and continued stay medical record review to gather information supporting medical necessity of the admission and communicate with third‑party payors.
Perform timely review of admissions utilizing InterQual criteria to assess appropriate level of care assignment. Review both inpatient admissions and patients placed in Observation.
Incorporate applicable governmental regulatory guidelines for Medicare and/or Medicaid admissions.
Submit clinical data to third‑party payors and document authorization in the electronic medical record system.
Perform continued stay reviews based on intensity of service, clinical response to care, expected length of stay, and readiness for discharge, or at intervals corresponding to authorized days.
Refer Observation or Inpatient admissions lacking documented medical necessity to the Physician Advisor and complete follow‑through to ensure correct level of care and billing based on the Physician Advisor’s determination.
Document pertinent clinical data on worksheets.
Ensure regulatory compliance and revenue integrity using appropriate billing policies.
Certify Medicare admission utilizing established admission screening criteria.
Duties & Responsibilities
Apply appropriate condition codes and modifiers in the electronic medical record system to communicate accurate claims information for billing.
Document denial information in the electronic medical record system, including attempts at resolution/overturning of the denial.
Provide all payor communication to be scanned into the system for use in appeals.
Maintain good working relationships with other departments within the revenue cycle.
Convey and receive information efficiently to and from third‑party payors, physicians, patients/families, physician practices, other members of the health care team, and external agencies.
Respect patient confidentiality and use discretion regarding protected health information.
Consult with attending physician when documentation in the medical record does not support admission or continued stay and seek to ensure completeness of all clinical documentation.
Function as a liaison between the Physician Advisor and the attending physician.
Serve as a resource to physicians, patients, physician practices, and other members of the health care team regarding issues related to patient classification and reimbursement.
Issue letters of non‑coverage in cases where the admission or continued stay is not certified, as necessary.
Ensure patient/family notification of Observation status and document it in the electronic medical record.
Communicate insurance authorization information to the physician’s office as requested.
Communicate with case management triad regarding reimbursement issues.
Use appropriate channels for reporting progress or concerns.
Participate in making appropriate and efficient discharge plans for patients on assigned areas.
Consult with members of the health care team effectively and efficiently regarding patient discharge plans.
Manage inpatient Medicare discharge expedited appeals process through the QIO.
Notify attending physician and other members of the health care team of inappropriate admissions, denials, end of authorized days, or other reimbursement‑impacting factors.
Consult physician advisor in cases where a patient demonstrates readiness for discharge, but there is no documented intent to discharge.
Identify and document potentially avoidable days in the electronic medical record system.
Assist Social Work staff to coordinate/obtain authorization for post acute services as needed.
Identify opportunities for improvement and coordinate/participate in the development and implementation of action plans to make improvements.
Participate in unit discharge planning activities and in interdisciplinary patient care conferences.
Identify abnormal patterns of utilization and refer to Manager/Director.
Recommend changes to system/processes to eliminate identified problems.
Represent the department on various committees/taskforces.
Adapt to change in a timely and positive manner.
Strive to meet department and hospital goals.
Perform all other duties as assigned by authorized personnel or as required in an emergency (e.g., fire or disaster).
Benefits
Day ONE medical, dental and life insurance benefits.
Health care and dependent care flexible spending accounts (FSAs).
Employee eligibility for enrollment into the 403(b) match plan day one – LHI matches dollar for dollar up to 6%.
Employer paid life insurance – equal to 1x salary.
Option to elect supplemental life insurance with low‑cost premiums up to 3x salary.
Adoption assistance.
Full‑time employees receive employer‑paid short‑term and long‑term disability coverage after 90 days of eligible employment.
Tuition reimbursement.
Student loan forgiveness.
Equal Opportunity Employer Lexington Health is an equal opportunity employer. We provide equal opportunity of employment for all individuals, remain compliant with applicable state and federal laws, and strive to create a discrimination‑free environment. We recruit, select, onboard, and employ all employees without regard to race, color, religion, sex, age, disability, national origin, veteran status, pregnancy, childbirth, or related medical conditions, including but not limited to lactation.
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Utilization Review Specialist
role at
Lexington Medical Center .
Part Time — Day Shift (7:00 AM – 3:00 PM).
Job Summary Performs admission and concurrent stay medical record review to determine appropriateness of admission, continued stay, and setting. Follows the patient throughout hospitalization, collaborating with attending physician and other health care providers. Communicates with third‑party payors to obtain authorization. Contributes to throughput and length of stay. Assists with denial management. Reviews physician medical record documentation and consults with physicians regarding completeness.
Minimum Qualifications
Minimum Education: ADN, Diploma Nursing Degree, or Bachelor of Science in Nursing.
Minimum Years of Experience: 3 years in an acute care hospital setting.
Required Licensure: Registered Nurse currently licensed in South Carolina.
No substitutable education or experience.
Essential Functions
Work in a cooperative manner, fostering favorable relations between employees, patients, families, visitors, fellow employees, and medical staff.
Exhibit commitment and pride by positively speaking of Lexington Medical Center, the department, employees, and guests.
Contribute to teamwork and create harmonious, effective, and positive working relationships with others.
Respect, understand, and respond with sensitivity to employees and guests.
Resolve conflicts and solve problems calmly, seeking solutions or referring to authority when appropriate, and aiming to deliver more than expected.
Exhibit telephone courtesy:
Answer promptly with name and department.
Speak with a pleasant tone while focusing on the caller.
Transfer calls correctly and promptly.
Attend to calls on hold in a timely manner.
Maintain confidentiality:
Disregard gossip.
Use discretion when discussing patient or LMC-related information.
Utilize the service recovery process to resolve complaints (GIFT).
Demonstrate competence in providing duties within the role.
Demonstrate competence to provide developmentally appropriate planning/review for patients of all age groups.
Identify need for professional growth and seek appropriate development opportunities, attaining a minimum of 15 hours of continuing education annually.
Serve as a role model for other members of the health care team.
Demonstrate receptiveness to change and flexibility in meeting department needs.
Assist in orientation and training of staff.
Perform admission and continued stay medical record review to gather information supporting medical necessity of the admission and communicate with third‑party payors.
Perform timely review of admissions utilizing InterQual criteria to assess appropriate level of care assignment. Review both inpatient admissions and patients placed in Observation.
Incorporate applicable governmental regulatory guidelines for Medicare and/or Medicaid admissions.
Submit clinical data to third‑party payors and document authorization in the electronic medical record system.
Perform continued stay reviews based on intensity of service, clinical response to care, expected length of stay, and readiness for discharge, or at intervals corresponding to authorized days.
Refer Observation or Inpatient admissions lacking documented medical necessity to the Physician Advisor and complete follow‑through to ensure correct level of care and billing based on the Physician Advisor’s determination.
Document pertinent clinical data on worksheets.
Ensure regulatory compliance and revenue integrity using appropriate billing policies.
Certify Medicare admission utilizing established admission screening criteria.
Duties & Responsibilities
Apply appropriate condition codes and modifiers in the electronic medical record system to communicate accurate claims information for billing.
Document denial information in the electronic medical record system, including attempts at resolution/overturning of the denial.
Provide all payor communication to be scanned into the system for use in appeals.
Maintain good working relationships with other departments within the revenue cycle.
Convey and receive information efficiently to and from third‑party payors, physicians, patients/families, physician practices, other members of the health care team, and external agencies.
Respect patient confidentiality and use discretion regarding protected health information.
Consult with attending physician when documentation in the medical record does not support admission or continued stay and seek to ensure completeness of all clinical documentation.
Function as a liaison between the Physician Advisor and the attending physician.
Serve as a resource to physicians, patients, physician practices, and other members of the health care team regarding issues related to patient classification and reimbursement.
Issue letters of non‑coverage in cases where the admission or continued stay is not certified, as necessary.
Ensure patient/family notification of Observation status and document it in the electronic medical record.
Communicate insurance authorization information to the physician’s office as requested.
Communicate with case management triad regarding reimbursement issues.
Use appropriate channels for reporting progress or concerns.
Participate in making appropriate and efficient discharge plans for patients on assigned areas.
Consult with members of the health care team effectively and efficiently regarding patient discharge plans.
Manage inpatient Medicare discharge expedited appeals process through the QIO.
Notify attending physician and other members of the health care team of inappropriate admissions, denials, end of authorized days, or other reimbursement‑impacting factors.
Consult physician advisor in cases where a patient demonstrates readiness for discharge, but there is no documented intent to discharge.
Identify and document potentially avoidable days in the electronic medical record system.
Assist Social Work staff to coordinate/obtain authorization for post acute services as needed.
Identify opportunities for improvement and coordinate/participate in the development and implementation of action plans to make improvements.
Participate in unit discharge planning activities and in interdisciplinary patient care conferences.
Identify abnormal patterns of utilization and refer to Manager/Director.
Recommend changes to system/processes to eliminate identified problems.
Represent the department on various committees/taskforces.
Adapt to change in a timely and positive manner.
Strive to meet department and hospital goals.
Perform all other duties as assigned by authorized personnel or as required in an emergency (e.g., fire or disaster).
Benefits
Day ONE medical, dental and life insurance benefits.
Health care and dependent care flexible spending accounts (FSAs).
Employee eligibility for enrollment into the 403(b) match plan day one – LHI matches dollar for dollar up to 6%.
Employer paid life insurance – equal to 1x salary.
Option to elect supplemental life insurance with low‑cost premiums up to 3x salary.
Adoption assistance.
Full‑time employees receive employer‑paid short‑term and long‑term disability coverage after 90 days of eligible employment.
Tuition reimbursement.
Student loan forgiveness.
Equal Opportunity Employer Lexington Health is an equal opportunity employer. We provide equal opportunity of employment for all individuals, remain compliant with applicable state and federal laws, and strive to create a discrimination‑free environment. We recruit, select, onboard, and employ all employees without regard to race, color, religion, sex, age, disability, national origin, veteran status, pregnancy, childbirth, or related medical conditions, including but not limited to lactation.
#J-18808-Ljbffr