Conduct medical certification review for medical necessity for acute care facility and services. Use nationally recognized, evidence-based guidelines approved by medical staff to recommend level of care to the physician and serve as a resource to the medical staff on issues related to admission qualifications, resource utilization, national and local coverage determinations, and documentation improvement opportunities.
This position also provides information (certified LOS and reimbursement issues) to the care team (RN, physicians, and case manager) as needed to ensure the appropriate and timely disposition of the client.
The Utilization Management RN, documents all chart and phone reviews, identifies and communicates potentially avoidable/non-reimbursed days, quality indicators (such as readmissions). Delivers non-covered letters as set forth by payer and/or regulatory compliance.
This position will be required to work a flexible schedule that may include evenings and weekends to provide coverage for the department as needed. This position participates in Quality Improvement initiatives.
Knowledge, Skills & Abilities
1. Strong interpersonal communication skills both verbal and written.
2. Knowledge of applicable regulatory requirements and community resources
3. Knowledge of continuous quality improvement process.
4. Philosophy consistent with the strategic plan of Renown Health
5. The ability to understand and resolve complex problems in a timely and effective manner using critical thinking skills.
6. The ability to keep current with new developments and acquire the needed knowledge for the position in order to keep skill sets up to date.
7. The ability to work under stress and to meet deadlines.
This position does not provide patient care.