Works under the supervision of the Director of Admissions/UR to develop improve, and implement the Hospital’s Utilization Review System, perform case management negotiations with insurance/HMO companies, and perform related work as required by the Director Of Admissions.
ESSENTIAL JOB DUTIES: Conducts timely reviews of all medical applications for admission, consulting with physicians, and other medical personnel as necessary throughout the review process. Performs timely assessments of all new admissions, to determine the appropriateness of the admission, as well as the proposed level of care. Conducts site visits as required to include, but not necessarily be limited to, residential homes, acute care facilities, and other long term care facilities. Functions as the in-house liaison with outside agencies and personnel, as well as with LTH personnel involved in the admission process, so as to facilitate timely admissions of patients/residents to LTH. Functions as the LTH liaison person with Medicare, Medicaid, Champus, and other insurers, so as to provide required documentation for the justification of the level of care for LTH patients/residents. Prepares all of the following in a timely and accurate manner: * Monthly committee reports; and
* All required departmental correspondence relating to utilization management (i.e. appeals to letters of denial). Attends and participates in weekly admissions meetings; monthly medical staff meetings; and quarterly Quality Assurance meetings. Responsible for the following patient/resident chart reviews: * Quarterly for Medicaid patients/residents;
* Monthly for Medicare, and private pay patients/residents;
* Monthly for Hospital-level patients; and
* As required by private insurance carriers/HMO’s.
Maintains individual records containing justification for the level of care, for all residents/patients. Provides documentation (with appropriate notifications) for patients/residents who are determined to be inappropriately placed according to level of care. Provides monthly UR chart reviews to the Medical Records Department. Updates UR worksheets in an appropriate and timely manner. Collects and mails all Control Packets and Discharge Tracking Sheets. Coordinates the semi-annual MDS/PIRS updates. Faxes pre-authorization paperwork for Medicaid applications, readmissions, and Medicare. Negotiates with various insurance carriers, and HMO companies on the admission, and continued stay of all Case Managed patients.
Status: Full Time
License : Current (unencumbered) license issued by the Virginia Board of Nursing to practice as a Registered Nurse.