Inpatient Util Mgmt Reviewer/Job Req 537176457
The Inpatient Utilization Management (UM) Reviewer is responsible for conducting on-site and telephonic utilization review of hospitalized members and initiating the transition of care process. The Inpatient UM Reviewer works directly with hospitals and primary and specialty care providers to meet the targeted needs of each individual member and their families.
Principal responsibilities include:
- Perform timely concurrent review of inpatient admission to ensure it meets medical necessity guidelines.
- Provide weekend coverage, when required, for assigned hospitals to ensure member discharge needs are met.
- Perform bedside assessment and counseling of members, including discussions of goals and expectations upon discharge or transfer.
- Use clinical judgment to assess and stratify members for appropriate levels of need and refer member to the Case and Disease Management department, if necessary.
- Identify patients eligible for hospital discharge or transfer to lower level of care; assist in coordinating discharge planning needs with hospital staff, vendors, etc. as appropriate
- Coordinate with admitting, attending, PCP, case manager, social workers, and other liaisons regarding the patient’s acuity level and plan of care.
- Communicate as needed with the Alliance Medical Director to validate patient acuity and plan of care; refer admissions for potential denial to the Medical Director.
- Participate in daily/weekly internal Alliance grand rounds. Participate in hospital grand rounds when appropriate.
- Receive, process, and review prior authorization requests for facility admissions, home health (PT/OT/ST), Durable Medical Equipment (DME), and out of area services.
- Perform timely concurrent reviews for patients belonging to delegate medical groups that seek inpatient admission out of the contiguous county.
- Identify members with medical conditions that may meet California Children’s Services (CCS) eligibility and coordinate with the plan CCS specialist for referral.
- Reconcile daily hospital census reports and face sheets against authorizations.
- Serve as the primary resource for inquiries and follow-up tasks related to the prior authorizations for the assigned hospital.
- Coordinate out of area patient transfers.
- Initiate the disenrollment process of Medi-Cal members and work in collaboration with UM coordinators to make sure the appropriate disenrollment process is implemented.
- Work closely with the Alliance Management or clinical personnel to better understand the reasons for modification, deferral, or denial of an authorization request.
- Support the Inpatient UM staff with administrative and clinical tasks as needed, including back-up coverage at hospitals as needed.
- Provide on call coverage during the weekend when required.
- Assist the Manager, Inpatient Utilization Management in tracking utilization and operational trends at hospitals and implementing solutions.
- Work with various departments at the Alliance to resolve inquiries into claims, authorizations, and eligibility.
- Establish and leverage relationships with contracted hospitals and providers to ensure the needs of the members are met and policies of the plan are followed.
- Complete other duties and special projects as assigned.
ESSENTIAL FUNCTIONS OF THE JOB
- Timely reviewing of inpatient admissions, bedside assessment and discharge planning of members.
- Coordinating other care management activities.
- Writing, reporting, administration, and analysis.
- Communicating effectively, both verbally and in writing.
- After hours support required on a rotational basis.
- Traveling to hospitals and clinics as needed.
- Complying with organizations Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.
- Constant and close visual work at desk or computer.
- Constant sitting and working at desk.
- Constant data entry using keyboard and/or mouse.
- Frequent use of telephone headset.
- Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person.
- Frequent lifting of folders and other objects weighing between 0 and 30 lbs.
- Frequent walking and standing.
- Frequent driving of automobiles.
Number of Employees Supervised: 0
EDUCATION OR TRAINING EQUIVALENT TO:
- Active California Registered RN license or Physician’s Assistant or Nurse Practioner required.
- Have a cleared TB test prior to or within seven days of hire.
- Current CPR and first aid card prior to or within six months of hire is preferred.
MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:
- One year experience in managed care or health care setting preferred.
SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):
- Excellent verbal and written communication skills.
- Ability to work within guidelines and protocols to achieve decisions independently.
- Excellent critical thinking and problem solving skills.
- Ability to work in cooperation with others.
- Ability to prioritize multiple projects as well as work with others.
- Working knowledge of managed care.
- Working knowledge of RVS, CPT ICD-9, ICD-10, and CPT 4.
- Ability to act as resource to department staff.
- Knowledge of DME and Home Health Services.
- Knowledge of ancillary and hospital based services.
- Current driver’s license, automobile insurance, and car registration required.
- Must maintain current nursing license.
- Proficient experience in Windows including current Microsoft Office suite.
Salary Range: $102,022.58 - $153,033.80