SPECIFIC ELEMENTS AND ESSENTIAL FUNCTIONS: This position will focus on initial and continued stay utilization review and denials to include assessment of medical records for appropriateness, level of care provided, including assessment of treatment modalities, medications, services and application of treatment protocols. A team approach with the facility Case Management team is critical. * Perform admission InterQual as per Plan contract or within 24 hours on all Non-Medicare Inpatients and document in Midas.
Will work with UR Manager, Denial Manager and Capital Division CM Director to implement process improvements to impact denials, LOS opportunities, improve provider relations etc.
Document note to support Inpatient admission.
Ensure the patient’s status is correct (Inpatient vs Outpatient)
Perform continued stay InterQual as per Plan contract, a minimum of every 3 days and submit to the Plan as needed.
Review concurrent denials and work with facility, physician and Plan to overturn the denial, document in Midas Denied Days screens.
Communicate denial status to the facility and physician.
Follow X-Code process as per HCA policy.
Communicate with physicians regarding patient status.
Communicate medical necessity and responder criteria to the facility Case Manager.
Review the Certification / Authorization report daily to determine deficiencies.
Documentation to take place in Midas in the Care Enhance Review Manager Enterprise (CERME), Midas Certification Entry, Midas Concurrent Review Entry and the Avoidable Denied Days module.
EDUCATION: B.S. in Business Administration, Nursing or Healthcare Administration preferred or equivalent work experience.
EXPERIENCE: Minimum 2 years’ experience in case management/utilization review required. InterQual experience required, minimum of one year. Acute care hospital experience preferred. Third Party Payer and Denial Management experience a plus. Experience with Midas (or other utilization review programs)
HOURS: Schedule flexible as per UR department needs. Ability to work weekends, holidays, evenings as needed from
Registered Nurse, RN - Utilization Review (Work From Home)
Virginia-Reston-Reston Hospital Center - Reston