Utilization Review Specialist

Dimension and Description

Primary Purpose: To review patient records to determine the medical necessity of admission, treatment, and length of stay at Cass Regional Medical Center in order to maintain compliance with government and insurance reimbursement policies. Assists with admission management for all admissions. Performs other duties as assigned.                               

Formal Policy-Setting Responsibilities: No formal responsibility. The policies associated with the job’s purpose and essential responsibilities are set by others.                                                          

Routine Decision Making: Assess the appropriateness of the level of patient care, diagnostic testing, clinical procedures and make recommendations to health care accordingly, utilizing the MCG Indicia guidelines as a resource.                               

Formal Supervisory Responsibility: No formal supervisory responsibility.                                              

Required Knowledge: Knowledge of insurance guidelines, admission criteria regulations, federal, state, and joint commission regulations as well as hospital policies and procedures and knowledge of medical terminology.

Required Skills and Ability: Strong communication skills; ability to work independently; proficient at computer use.                                               

Unusual Working Conditions: Risk of blood, bodily fluid. Potential exposure to hazardous drugs and chemicals.                                                             

Education and Certification: Two (2) or four (4) year RN degree required. BSN preferred. MO or Compact RN license with 2 years of Med Surg bedside nursing required. Working knowledge/experience in utilization review management, managed care and payer issues preferred. MCG certificate recommended after 1 year of acceptance.

Age Specific Competencies: Pediatric/child patients between (2 yrs-12 yrs); adolescent patients between 12 to 18 years of age; adult patients between 18 to 64 years; and geriatric patients 65 years and older.                                     

Essential Responsibilities and Tasks

A.            Works in collaboration with providers and other healthcare personnel in patient evaluation and treatment. (30% of the time)                                                                                                                           

1.            Communicates with providers as appropriate regarding daily patient care and coordination.         

2              Completes and maintains case management within electronic health record on each scheduled work day, utilizing the MCG Indicia model interface with Meditech.

3.            Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency.

4.            Supports department based goals which contribute to the success of the organization; serves as a preceptor, mentor and resource to less experienced staff.

5.            Serves as a resource for admission criteria guidelines.

6.            Utilizing the ‘AIDET’ (Acknowledge, Introduction, Duration, Explain, Thank) model, conducts an appropriate introduction, reviews the plan of care, mutually sets attainable patient goals.

B.            Performs insurance pre-certifications and appeals daily on a case by case basis. (65% of the time)          

1.            Performs admissions, concurrent focused reviews and inpatient certifications on each scheduled workday.

2.            Serves as a resource person and provides counseling and intervention related to treatment and disposition.                                                        

3.            Assists with the appeals process for insurance denials daily on a case by case basis.          

4.            Maintains hospital guidelines for release of records and patient confidentiality daily.       

5.            Assists case management manager with yearly review and revisions of utilization review policy and procedure manuals to maintain compliance.       

ESSENTIAL PHYSICAL REQUIREMENTS

TYPE OF WORK (Check One)                                                                       

Sedentary Work: Lifting 10lbs maximum and occasionally lifting and/or carrying such articles as dockets, ledgers and small tools.  Jobs are sedentary; if walking and standing are required only occasionally.                                                           

x              Light Work: Lifting 20lbs maximum with frequent lifting and/or carrying of objects weighing up to 10lbs.  Even though the weight lifted may be only a negligible amount, a job is in this category when it requires walking or standing to a significant degree or pushing and pulling of arm and/or leg controls.

Medium Work: Lifting 100lbs maximum with frequent lifting and/or carrying of objects weighing up to 25lbs.                                                               

Heavy Work: Lifting 100lbs maximum with frequent lifting and/or carrying of objects weighing up to 50lbs.                                                               

Very Heavy Lifting: Lifting objects in excess of 100lbs with frequent lifting and/or carrying of objects weighing 50lbs or more.

PHYSICAL DEMANDS (Check those which apply)

x              Lifting: Raising or lowering an object from one level to another (includes upward pulling).              

x              Carrying: Transporting an object, usually holding it in hands or arms or on the shoulders                

Pushing: Exerting force upon an object so that the object moves away from the force (including slapping, striking, kicking, and treadle actions).                                                     

Pulling: Exerting force upon an object so that the object moves toward the force (includes jerking).                                                          

Climbing: Ascending or descending ladders, stairs, scaffolding, ramps, poles, ropes, and the like, using the feet and the legs and/or hands and arms.

Balancing: Maintaining body equilibrium to prevent falling when walking, standing, crouching, or running on a narrow, slippery, or erratically moving surfaces; or maintaing body equilibrium when performing gymnastic feats.                                                                                                    

x              Hearing: Ability to determine audible communication.                                                   

x              Stooping: Bending the body downward and forward by bending the spine at the waist.   

x              Kneeling: Bending the legs at the knees to come to rest on the knee or knees.                    

x              Crouching: Bending the body downward and forward by bending the legs and spine.                       

                Crawling: Moving about on the hands and knees or hands and feet.                                                         

x              Reaching: Extending the hands and arms in any direction.                                                             

x              Handling: Seizing, holding, grasping, turning, or otherwise working with the hand or hands (fingering not involved).                                                           

x              Fingering: Picking, pinching, or otherwise working with the fingers primarily (rather than with the whole hand or arms as in handling).                                                                

x              Repetitive Motions: Substantial movements (motions) of the wrist, hands, and/or fingers.

x              Feeling: Perceiving such attributes of objects and materials as size, shape, temperature, or texture by means of receptors in the skin, particularly those of the finger tips.                                        

x              Speaking: Expressing or exchanging ideas by means of the spoken word.  Those activities in which they must convey detailed or important spoken instructions to other workers accurately, loudly, or quickly.                                               

x              Seeing: Obtaining impressions through the eyes of the shape, size, distance, motion, color or other characteristics of objects.                                                            

                Including Major Visual Functions                                                              

x              Acuity, far - clarity of vision at 20 feet or more.                                                  

x              Acuity, near - clarity of vision at 20 inches or less.                                                             

x              Depth perception - ability to judge distance and space relationships so as to see objects where and as they actually are.                                                      

x              Field of vision - area seen up and down or to the right or left while eyes are fixed.             

x              Accommodations - adjustment of the lens of the eye to bring an object into sharp focus.

x              Color vision - the ability to identify and distinguish colors.

WORKING CONDITIONS (Check those which apply)

x              Inside: Worker spends approximately 75% or more of time inside.                                                            

                Outside: Worker spends approximately 75% or more time outside.                                                          

                In/Outside: Activities occur inside or outside in approximately equal amounts.                                    

Extremes of Cold: Temperature sufficiently low to cause marked bodily discomfort unless worker is provided with exceptional protection.                                                                      

Extremes of Heat: Temperature sufficiently high to cause marked bodily discomfort unless worker is provided with exceptional protection.                                                                      

Temperature Changes: Variations in temperature which are sufficiently marked and abrupt to cause noticeable bodily reactions.                                                                                        

                Wet: Contact with water or other liquids.                                                             

Humid: Atmospheric condition with moisture content sufficiently high to cause marked bodily discomfort.                                                               

Noise and Vibration: Sufficient noise, either constant or intermittent to cause marked distraction or possible injury to the sense of hearing and /or sufficient vibration (production of an oscillating movement or strain on the body or its extremities from repeated motion or shock) to cause bodily harm if endured day after day.                                                                                                               

                Hazards: Situations in which the individual is exposed to the definite risk of the bodily injury.       

Fumes: Smoky or vaporous exhalations, usually odorous, thrown off as the result of combustion or chemical reaction.                                                             

Odor: Noxious smells, either toxic dust, fumes, gases, vapors, mists or liquids which cause general or localized disabling conditions as a result of inhalation or action to the skin.

Toxic Conditions: Exposure to toxic dust, fumes, gases, vapors. Mists or liquids which cause general or localized disabling conditions as a result of inhalations or action to the skin.

Infectious Disease: Risk of exposure to biohazardous materials, blood, body fluid contamination.

Dust:  Air filled with small particles of any kind, such as textiles dust, flour, wool, leather, feathers, etc., and inorganic dust including silica and asbestos, which make the workplace unpleasant or are the source of occupational disease.                                                                                    

Poor Ventilation:  Insufficient movement of air causing a feeling of suffocation; or exposure to drafts.

Identify and describe any additional physical demands or unusual working conditions that were not previously covered. _______________________________________________________