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Utilization Review Clinical Specialist

3 months ago

Franklin, Tennessee, United States Community Health System Full time
Job Description

Community Health Systems is one of the nation's leading healthcare providers.

Developing and operating healthcare delivery systems in 41 distinct markets across 15 states, CHS is committed to helping people get well and live healthier.

CHS operates 74 acute-care hospitals and more than 1,000 other sites of care, including physician practices, urgent care centers, freestanding emergency departments, occupational medicine clinics, imaging centers, cancer centers and ambulatory surgery centers.


Summary:


Utilization management is the analysis of the necessity, appropriateness, and efficiency of medical services and procedures in a Behavioral Health setting.

Utilization review is the assessment for medical necessity, both for admission to the BHU as well as continued stay.

This function ensures that services are not only appropriate, but ensures that an authorization for services is obtained from payer, if required, and that documentation supports the care delivered in such a way that minimizes the risk of denials after discharge.


Essential Duties:

  • Initial clinical assessments, continued stay assessments, and payer requested reviews are performed using evidence based criteria as designed, medical experience based problem solving skills, and following the established policies and regulations governing this process in order to either obtain authorization or establish psych/medical necessity for hospitalized patients.
  • Hold collaborative discussions with physicians on the medical staff, when needed, to obtain additional documentation in the record to support hospital medical necessity, discharge needs, or fulfill other payer requirements. These discussions are to help the UR Clinical Specialist understand the reason for admission, and better be able to request appropriate additional documentation from the physician(s).
  • Escalates cases to the Utilization Review Manager and/or Physician Advisor if physicians are unable to provide any additional information to support the need for medically necessary Behavioral Health care.
  • Documents all actions and activities in the case management software system used by the BHU. This documentation includes, but is not limited to, clinical reviews, escalations, avoidable days, payer contacts, authorization numbers, DRG etc. Documentation may also be made in other systems as required based on hospital and/or corporate policies/procedures.
  • In the event of concurrent denials, the UR Clinical Specialist reviews the denial and works with the physicians on the medical staff hospital's to perform an internal secondary review. The UR Clinical Specialist may assist coordinating a Peer to Peer discussion according to hospital and/or corporate direction. Results of the Peer to Peer are to be gathered from the physician presenting after the call and documented in the case management system by the UR Behavioral Health Review Specialist.
  • UR Clinical Specialist communicates with the UR Coordinator and facility case manager(s) (i.e. licensed social workers, discharge planners, etc.) in person, telephonically, and/or through the case management software to ensure effective collaboration between all disciplines managing a patient's care.
  • UR Clinical Specialist communicates with Insurance providers and case manager(s) in person, telephonically, and/or through provider software to ensure effective collaboration for prospective, concurrent and retrospective reviews/authorizations.

Qualifications:

  • Required Education: Associates Degree in Nursing
  • Preferred Education: Bachelors Science Nursing or higher
  • Required Experience: At least 3 years previous psych nursing experience
Preferred Experience: 3 plus years Utilization review experience

  • Required License/Registration/Certification: Licensed Practical Nurse or Licensed Registered Nurse
  • Preferred License/Registration/Certification: ACM or CCM Certification
  • Computer Skills Required: Data entry skills; Demonstrable skills with Google Docs, Google Sheets, and email applications.
  • Skills: Ability to prioritize assignments and effective time-management skills
Basic knowledge of clinical and psychosocial aspects of patient care

Must be detail oriented, flexible, and committed to patient advocacy

Demonstrates skills in planning, organizing, and managing multiple functions and complex processes

Excellent verbal and written communication skills required

Physical Demands:
In order to successfully perform this job, with or without a reasonable accommodation, the following are outlined below:

  • The Employee is required to read, review, prepare and analyze written data and figures, using a PC or similar, and should possess visual acuity.
  • The Employee may be required to occasionally climb, push, stand, walk, reach, grasp, kneel, stoop, and/or perform repetitive motions.
  • The employee is required to sit or stand at a desk for up to 8 hours a day.
  • The Employee is not substantially exposed to adverse environmental conditions and; therefore, job functions are typically performed under conditions such as those found within general office or administrative work. May be exposed to biohazardous material and pathogens.