Performs and monitors integrated, concurrent utilization review and case referrals on patients, consistent with the approved Utilization Review Plans. Works with medical and professional staff to obtain appropriate clinical documentation for review and optimal patient placement. Maintains contact with Managed Care and other third party payors to assure appropriate case management.
Essential Job Duties:
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions
- Performs duties according to established standards for age groups adolescence through geriatric.
- Assesses data reflective of the patient’s status and interprets the appropriate information needed to identify each patient’s requirements relative to his or her age-specific needs. Maintains monthly statistical data and reports data to Clinical Director.
- Identifies status of physical, social and psychological needs of the patient, family and significant others.
- Evaluates data obtained in the bio-psychosocial and nursing history and assesses patients and their families to determine by interview, appropriateness for admission or referral.
- Determines the medical necessity and appropriateness of admission, using established criteria and standards.
- Verifies that pre-admission assessment is performed, and pre-authorizes patients as applicable.
- Monitors medical records for medical necessity and appropriateness of continued stay in accordance with established and approved norms.
- Verifies prior authorization data and performs concurrent reviews with external review agents on a daily basis in order to provide medical necessity and intensity of service information for continued stay approvals.
- Consolidates, tracks and reports performance on completed utilization review forms for all clinical areas and relays information to the multi-disciplinary treatment team.
- Resolves matters on outliers and initiates/follows up on appeals for determination at variance with program norm.
- Two years of experience performing utilization review or utilization management.
Working Conditions, Equipment, Physical Demands:
There is a reasonable expectation that employees in this position will not be exposed to blood-borne pathogens.
Physical Demands –
Light work. Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly to move objects. If the use of arm and/or leg controls requires exertion of forces greater than that for sedentary work and the worker sits most of the time, the job is rated for light work.
The physical demands and work environment that have been described are representative of those an employee encounters while performing the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions in accordance with the Americans with Disabilities Act.
The above job description is an overview of the functions and requirements for this position. This document is not intended to be an exhaustive list encompassing every duty and requirement of this position; your supervisor may assign other duties as deemed necessary.