Utilization Review Specialist - AHS Vista LLC

Analyzes patient records to determine legitimacy of admission, treatment, and length of stay in the health-care facility to comply with government and insurance company reimbursement policies: Analyzes insurance, governmental, and accrediting agency standards to determine criteria concerning admissions, treatment, and length of stay of patients.

Responsibilities:

• Reviews application for patient admission and approves admission or refers case to facility utilization review committee for review and course of action when case fails to meet admission standards.
• Compares inpatient medical records to established criteria and confers with medical and nursing personnel and other professional staff to determine legitimacy of treatment and length of stay.
• Abstracts data from records and maintains statistics.
• Determines patient review dates according to established diagnostic criteria.
• May assist review committee in planning and holding federally mandated quality assurance reviews.
• May supervise and coordinate activities of utilization review staff.
• Research clinical records, appropriate insurance regulations and history of claim to determine next step.
• Monitor day to day compliance of appeal decision time frames and collaborate with other departments to ensure timely resolution of issues or appeals.
• Review clinical and medical records for completeness and determine administrative or clinical appeal. Assign reviews to physician advisors and medical directors for those requiring medical necessity reviews.
• Coordinate first and second level appeals.
• Consults with managers on problem cases and interfaces with case managers, clinical supervisors, account managers and other personnel in resolving denial and appeal questions.
• Ensure proper documentation of all denials into billing systems to include tracking outcome for reporting to appropriate parties.
• Manage first level appeals to ensure timely submissions.
• Monitor volume of appeals in order to engage additional resources when needed.
• Form professional relationships with payer appeals and utilization departments.
• Enter all data related to appeals and case reviews into a database.
• Prepare and present information on appeals to applicable committees and personnel as requested.
• Demonstrate ability to draft professional letter by incorporating supporting documents, policies and statutes.

Requirements:

• Current IL issued RN license
• Graduate from an accredited nursing school.