Utilization Review Case Manager

SCOPE OF POSITION :

The Utilization Review Case Manager (UR CM) works in collaboration with the physician and interdisciplinary team to support the underlying objective of enhancing the quality of clinical outcomes and patient satisfaction while managing the cost of care and providing timely and accurate information to payers. The role integrates and coordinates utilization management and denial prevention by focusing on identifying and removing unnecessary and redundant care, promoting clinical best practice, and ensuring all patients receive "the right care, at the right time, and in the right setting". The UR CM is responsible for preoperative, concurrent, and retrospective reviews in accordance with the utilization management plan. The UM CM ensures the appropriate status and level of care is determined and ensures accurate assessment of medical necessity, thus appropriate reimbursement. Performs duties in support of ECHN mission to ensure the highest quality of patient care in an economically sound and efficient manner.

RESPONSIBILITIES :

• Conducts concurrent and retrospective review(s) utilizing InterQual (IQ), Milliman Care Guidelines (MCG), or in accordance with CMS rules and regulations for medical necessity criteria to monitor appropriateness of admissions and continued stays, and documents findings based on department policy / procedure; refers appropriate cases to Physician Advisor for recommendation(s).
• Ensures order in chart / EMR and status coincides with the IQ or MCG review or CMS rules and regulations for appropriate Level of Care and status on all patients through collaboration with Case Manager.
• Demonstrates thorough knowledge in the application of medical necessity criteria.
• Assess the safest and most efficient care level based on severity of illness, comorbidities and complications, and the intensity of services being delivered.
• Utilizes appropriate payer criteria to provide recommendation(s) to the attending physician
• Communicates payor criteria and issues on a case-by-case basis with multidisciplinary team and follows up to resolve problems with payors as needed; initiates peer to peer when appropriate.
• Contacts the attending physician for additional information if the patient does not meet the appropriate medical necessity criteria or in accordance with CMS rules and regulations for continued stay.
• Escalates reviews timely to physician advisor timely for lack of medical necessity and / or status discrepancies.
• Educates physicians and interdisciplinary team regarding approved criteria practice guidelines, level of care, length of stay, and alternative treatment options.
• Supports multi-disciplinary strategies to reduce length of stay, reduce resource consumption, and achieve positive patient outcomes.
• Collaborates with multidisciplinary team members to identify and implement strategies to ensure appropriate utilization and achieve positive patient outcomes.
• Demonstrates knowledge of target length of stay and GMLOS for diagnosis by actively monitoring length of stay timeframe and implementing measures to achieve targets.
• Prevents denials by providing timely clinical reviews to payers for authorization of services provided and completes case review for claim reimbursement.
• Reviews outlier cases to determine level of care and clinical appropriateness.
• Assists as appropriate in the collection and reporting of financial indicators including length of stay, approved, denied, and avoidable days, and resource utilization.
• Demonstrates skill in communicating with physicians the necessary documentation to demonstrate medical necessity.
• Utilizes data to drive decisions related to utilization management for assigned patients, including fiscal and clinical data.
• Responsible for yearly re-education on industry standard criteria, i.e., InterQual / Milliman Care Guidelines.
• Collects and analyzes data to provide information regarding system barriers to care delivery, patient care outcomes, resource trends and patterns.
• Advocates for, supports and protects the rights of patients. Promptly reports any potential compromise of rights to appropriate individual (s).
• Identifies quality, infection control, utilization, and risk management issues with referrals to appropriate committee / personnel.
• Continuously pursue excellence in meeting the needs and expectation of all customers (patients, families, inter-disciplinary team members, payors, screener, liaisons and outside services and agencies.
• Performs all other duties as assigned.

REQUIREMENTS :

COMPETENCIES :

REVISED DATE : 10 / 21 / 2021