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Patient Care Utilization Analyst

2 months ago

Waukegan, Illinois, United States AHS Vista LLC Full time
Job Overview

The role of a Patient Care Utilization Analyst involves the critical evaluation of patient documentation to assess the validity of admissions, treatments, and duration of stay within healthcare facilities, ensuring adherence to reimbursement guidelines set forth by governmental and insurance entities.

Key Responsibilities:

  • Evaluate patient admission requests and either approve them or escalate cases to the facility's utilization review committee for further examination when standards are not met.
  • Assess inpatient medical records against established benchmarks and collaborate with medical and nursing staff to validate treatment appropriateness and length of stay.
  • Extract and compile data from patient records while maintaining comprehensive statistics.
  • Set patient review timelines based on established diagnostic criteria.
  • Assist the review committee in organizing federally mandated quality assurance evaluations.
  • Oversee and coordinate the activities of the utilization review team as necessary.
  • Investigate clinical records, relevant insurance regulations, and claims history to determine subsequent actions.
  • Ensure compliance with appeal decision timelines and work with various departments to facilitate prompt resolution of issues or appeals.
  • Examine clinical and medical records for thoroughness and identify whether an administrative or clinical appeal is warranted. Assign reviews to physician advisors and medical directors for cases needing medical necessity evaluations.
  • Facilitate first and second level appeals processes.
  • Consult with management on complex cases and collaborate with case managers, clinical supervisors, account managers, and other personnel to address denial and appeal inquiries.
  • Guarantee accurate documentation of all denials in billing systems, including tracking outcomes for reporting purposes.
  • Manage first level appeals to ensure timely submissions.
  • Monitor appeal volumes to engage additional resources as required.
  • Establish professional relationships with payer appeals and utilization departments.
  • Input all data related to appeals and case evaluations into a centralized database.
  • Prepare and deliver presentations on appeals to relevant committees and personnel as needed.
  • Exhibit proficiency in drafting professional correspondence by integrating supporting documents, policies, and regulations.

Qualifications:

  • Valid RN license issued in Illinois.
  • Graduation from an accredited nursing program.
  • Familiarity with InterQual Level of Care Criteria and Milliman & Robertson Criteria, along with knowledge of third-party payer regulations concerning utilization and quality review, is preferred.