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Children’s Hospital of Michigan is an international leader in pediatric and adolescent medicine. Surgical services include general, thoracic, reconstructive and cardiovascular. Imaging technology designed specifically for children provides advanced diagnostic services including Positron Emission Tomography (PET) and MRI. The Children’s Hospital of Michigan Emergency Department is a verified Level 1 Pediatric Trauma Center and dedicated pediatric burn center. Experts in pediatric critical care, rehabilitation, and neonatal and perinatal medicine provide care for thousands of children every year at Children’s Hospital of Michigan, Children’s Hospital of Michigan - Troy and six ambulatory sites.
Job Summary
Under general direction and according to established policies and procedures, monitors patient care for quality assurance, utilization review and risk management activities. Determines appropriateness and medical necessity of admission, continued hospital stay and use of ancillary services. May perform pre-authorizations, concurrent review and retrospective review audits.
May troubleshoot patient issues with Patient Management, as needed. Reviews and monitors patient medical records for complete, timely and accurate entries.
Communicates with third party payors and develops appeals to overturn adverse payment decisions; provides technical assistance to clinical and administrative staff regarding the development of quality improvement indicators/monitors, measurement methodology and charting techniques; conducts special studies and prepares report findings.
May participate in the development, education and maintenance of the DMC Continuous Improvement Program.
Facilitates the preparation of JCAHO and other licensing body requirements of accreditation. Develops and presents in-services to clinical and administrative staff regarding documentation and findings from reviews, as necessary.
1. Bachelors degree in Nursing, Medical Records or health care field, or equivalent combination of education and/or related experience. Registered Nurse preferred.
2. Two to three years progressively more responsible clinical and/or Quality Assurance/utilization Review experience.
3. Coursework and experience in research statistics and quality improvement methodology, including chart control techniques, preferred.
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