PURPOSE STATEMENT

Responsible for review of all inpatient and outpatient admissions to the hospital for appropriateness and manages all access points for admission to the hospital including but not limited to Emergency Department admissions, direct admissions, transfers into and out of the ED, other facilities, and admissions from outpatient areas. Evaluates the medical necessity, appropriateness, and efficient use of health care services of all hospitalizations, inpatients or outpatients.  Skilled with the application of InterQual and MCG criteria, works collaboratively with the physicians, healthcare team and the care coordinator to optimally certify the level of care and facilitates the patient’s movement through the continuum of care as appropriate.

ESSENTIAL FUNCTIONS  

• Monitor use of healthcare resources, collaborate with physicians to ensure patient receives diagnostics/evaluations in the proper setting (i.e. inpatient vs. outpatient).
• Maintain current knowledge of Condition Code 44, Hospital CoP’s and CMS (Medicare) rules and regulations.
• Serve as an expert resource to physicians, healthcare staff in the application of InterQual and MCG, and use of evidence-based practices.
• Serve as patient advocate and enhance a collaborative relationship between the physician and multidisciplinary team with the patient and family to maximize informed decisions.
• Communicate effectively with third party payors regarding certification, completes initial review prior to or at time of admission. 
• Maintain knowledge of InterQual and MCG medical necessity criteria and apply appropriately.
• Identify the need to clarify documentation through quality audits in records and initiate communication with physicians utilizing appropriate ‘query’ tools in order to capture documentation in the medical record to accurately support the patient’s severity of illness.
• Demonstrate knowledge of documentation requirements and guidelines.
• Assist in the improvement of overall quality and completeness of clinical documentation by ensuring that documentation clarification with physicians has been recorded in the patient’s chart.
• Review clinical data for ED admits, make level of care recommendations to the ED physician, and obtain any additional clinical information to assist in the level of care determination.
• Manage all direct admits, clarify level of care orders and perform InterQual screening as appropriate. Acquires additional information if necessary to assist in the level of care determination.
• Review all requests for changes in status for admission from the PACU or any outpatient areas. Apply InterQual and MCG criteria to determine appropriateness for the level of care requested and consult with Attending if necessary.
• Ensure the operative procedure performed is the operative procedure prior-authorized with the third-party payor and communicate any variance.
• Serve as a resource for facilitating patient transfers, including but not limited to, obtaining or providing clinical information from/to the referring/accepting facility. Perform clinical reviews of all inbound transfers for appropriateness.
• Demonstrate a working knowledge of HIPAA guidelines and utilize them in all aspects of communication with customers.
• Cooperate/communicate with the QIO when a Medicare patient has appealed for their discharge.
• Consult the Physician Advisement process to resolve issues and refer appropriate cases per established protocol.
• Adhere to and implement the Utilization Management Plan per CMS Conditions of Participation.
• Report and document adverse events and reportable conditions.
• Consistently follows departmental procedures regarding level of care (service) changes.
• Discuss cases with particular issues relating to utilization appropriateness with Manager/Director and notify appropriate peoples when indicated.
• Display a high level of flexibility, adaptability, and organizational skills in response to the workload and effectively prioritize work while maintaining productivity.
• Assist with collection of data for case management metrics per the UM Plan.
• Support the Medical Center quality improvement process by identifying and appropriately communicating potential quality issues and participating in focused quality monitoring (i.e. concurrent notification of ADRS, sentinel events, etc.).
• Contribute to the development of competencies related to job functions and participate in competency evaluations.
• Participate in department-based Performance Improvement activities.
• Review patient’s medical record for over, under and inappropriate utilization. Reviews for justification of patient admission and continued stay. Conduct timely and accurate interventions and follow-through.
• Inform Patient Financial Services of patients in need of financial counseling.
• Track and document avoidable days and readmissions with proactive, concurrent action taken when indicated.
• Maintain regular and predictable attendance.
• Perform other essential duties as assigned.

EDUCATION/EXPERIENCE/SKILL REQUIREMENTS 

• High school diploma or equivalent.
• Currently licensed to practice as a professional Registered Nurse (RN) in the state of Missouri.
• 3-5 years of recent hospital-based patient care required.
• 3-5 years Milliman or InterQual experience preferred.
• HMO, managed care, PPO, Utilization Management/medical management experience is a plus.
• Strong computer skills, excellent communication skills, team building, and leadership ability.
• Must be self-motivated and have the ability to work within the established policies, procedures and practices prescribed by the hospital/clinic.

PHYSICAL/MENTAL REQUIREMENTS 

• Must be able to sit and stand, intermittent 8 to 10 hours a day.
• Must be able to use standard office equipment, including the telephone and computer keyboard.
• Continuously works under pressure of near 100% accuracy while meeting inflexible deadlines.
• Continuously utilizes manual/bi-manual dexterity, near vision, speech, and hearing.
• Frequently stands, walks, sits and utilizes eye/hand coordination and color definition.
• Occasionally reaches above shoulder, regularly required to lift and/or carry up to 40 lbs.
• Occasionally walks on uneven surfaces.