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Franciscan Healthcare is looking for a Utilization Review/Concurrent Analyst to perform case reviews, check medical records, speak with patients and care providers regarding treatment, and respond to the plan of care. You will also make recommendations regarding the appropriateness of care for identified diagnoses based on the research results for those conditions.
Hours: Minimum 40 hours/week; Monday-Friday 7:30am-4:30pm
ESSENTIAL JOB DUTIES AND RESPONSIBILITIES:
- Complete daily/concurrent Utilization Management reviews of all current Inpatients, Swing Bed patients, Outpatient Observation patients, Outpatient and Ambulatory Surgery patients using Milliman Care Guidelines and Cerner EHR, on a rotation schedule with other Utilization Review/Management personnel.
- Insurance authorization for the patient’s specific setting
- Follow-up reviews as required/requested by the individual insurance group
- Appropriateness of the assigned hospital setting
- Review for documentation requirements by medical staff
- Assignment of working DRG on admission
- Assignment of appropriate MCG guideline criteria based on admission information
- Monitor and complete initial and follow-up IMM for Medicare, Medicare Advantage and TRICARE inpatients
- Complete appropriate notices as applicable for patient’s hospital stay per UM Policy and Procedures
- Monitor the 2-midnight rule for Medicare patients in the Outpatient Observation setting and advise physicians regarding appropriateness of admission and documentation
- Responsible for remaining up-to-date and knowledgeable of regulations and remain current about federal legislative changes that affect patient outcomes.
- Work closely with all hospital departments to assure accuracy in patient’s encounter.
- Work with physicians, PA’s and NP’s to resolve issues/questions and documentation to assure accurate claim submission.
QUALIFICATIONS:Â
Education and/or ExperienceÂ
- RN / LPN preferred or Utilization Management background.
- Knowledge of ICD-10-CM and ICD-10-PCS coding system, or willingness to learn.
- Knowledge of current CPT coding principles and guidelines, or willingness to learn.
- Knowledge of Medicare/Medicaid/Insurance regulations; or willing to learn.
Other Competencies
- Ability to maintain strict confidentiality in all hospital/patient related matters.
- Excellent written and oral communication skills including the English language.
- Computer skills necessary, experience with Electronic Health Record.
- Ability to pay close attention to detail.
- Ability to communicate effectively with physicians, outside insurance reviewers, clinic personnel, nursing home personnel, patient’s and patient families as well as other hospital departments.
- Ability to accept change in regard to policy/procedure; CMS/insurance rules/regulations, frequently and at times with little or even retrospective notice.
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