Job Summary: Completes initial review for medical necessity for all admissions in assigned area(s), applying established criteria within 24 hours of admission. Assesses patient status, whether outpatient, observation, or inpatient and determines appropriateness of status and level of care based on criteria (Ex: Interqual). Communicates with physicians to ensure status and medical necessity are accurately determined. Refers to physician advisor and /or second level reviewer when necessary. Documents initial review, communications, and referrals in permanent medical record. For all observation patients in assigned areas, daily reviews of medical necessity will be performed and documented in medical review, including daily status update while patient is in observation status. Ongoing continued stay reviews are done for assigned areas. Concurrent reviews are to be documented in patient medical record and shared with managed care organizations when requested. Assesses for best utilization regarding level of patient care, diagnostic testing, and clinical procedures without jeopardizing patient quality efforts. Identifies and reports avoidable days. Acts as liaison to managed care organizations. Communicates with attending physicians regarding utilization issues. Collaborates with discharge planning specialist and other disciplines.

Retrospectively reviews discharged medical record for medical necessity criteria and sends pertinent clinical information to meet guidelines for additional length of stay to MCO via fax, Provider Link, or telephonically. Gathers and disseminates Utilization Management information to medical staff departments, Nursing departments, Care Management and Senior management as necessary. Retrospectively reviews medical record for clinical denials. Composes a detailed summary of care and sends appeals to MCO, Medicare, or RAC for reversal of original determination. May serve on the Medical Record/ Utilization Review Committee, providing detailed logs of denial activity and appeal results. Maintains the Status Change Database. Performs retrospective clinical reviews/appeals as part of denial process.

The UR Specialist will be cross trained to work for the Commercial Resource Analyst when the need arises. Act as liaison to managed care organizations. Communicates with attending physicians regarding utilization issues. Assign patients that have had insurance verified to the UR Specialists on Provider Link. Send corresponding initial clinical and H&P’s to commercial companies, managed Medicare, VA, and SC Medicaid. Serve on committees as assigned. Perform other duties as assigned.

Qualifications: Bachelor’s degree from an accredited college with a clinical background. BSN required. Current RN license to practice in NC (NC license or multi-state (compact) license). Certification in Utilization Review / Management, Quality and/or Case Management preferred. Minimum of three years experience in clinical area with clinical review experience. Requires excellent oral and written communication skills. Must be able to organize and prioritize work assignment. Proficient with required IT Systems including Interqual, Microsoft Word and Excel. Performs other duties as assigned.

EOE AA M/F/VET/Disability