Utilization Review Case Manager

2 weeks ago


Stony Brook, New York, United States Stony Brook Medicine Full time
Job Summary

The Utilization Review Case Manager position at Stony Brook Medicine is responsible for providing quality concurrent review to screen patients for level of care, including inpatient, observation, emergency, and outpatient services. This role requires conducting concurrent and retrospective chart reviews for potential verbal or written appeal of days denied for all payers, including commercial, government, and external denials.

Key Responsibilities
  • Provide Utilization Review Screens for Short Stay and Observation Reviews, including inpatient stays less than 72 hours.
  • Provide Utilization Review for the Emergency Room and all inpatient units as needed.
  • Review Observation cases and provide appropriate documentation.
  • Review Medicare and Medicaid Cases, following the process for Condition 44 on all Medicare cases.
  • Follow the process for change of inpatient to outpatient status on all payers excluding Medicare.
  • Document avoidable delays and days.
  • Conduct Retrospective review for potential verbal or written appeal of all denied cases, including communication with the Attending MD if the patient is still hospitalized.
  • Participate proactively and collaboratively to reduce denials and enhance reimbursement.
  • Document and maintain data to identify and analyze patterns, trends, and solutions on all denial activity.
  • Promote continuous quality improvement on identified issues.
  • Promote efficient use of hospital resources.
  • Collaborate with the interdisciplinary team on all complex cases.
  • Maintain high customer service at all times.
Qualifications
  • NY RN License.
  • Bachelor's Degree.
  • Three to Five years RN experience in an Acute Care Hospital.
  • Working knowledge of MCG or Interqual.
  • Knowledge of Regulatory agencies and standards of care.
  • Computer Skills in Word, Excel, and PowerPoint.
  • Excellent Communication Skills.
  • Creative, flexible, professional, and courteous.
  • Weekday and weekend flexibility.
Preferred Qualifications
  • Master's Degree.
  • Experience or Certified in Case Management, Quality, Risk, MCG, CDI, or Utilization Management.
  • PRI certified.
  • Demonstrate experience in Appeal and Denial writing.
  • Proficient in Word and Excel and other computer skill sets.
  • Experience with Psychiatry, Pediatrics, or Neonatal Care.
  • Coding Experience.
  • Bilingual.


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