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Medical Necessity Reviewer
2 months ago
The Clinical Utilization Review Specialist will work collaboratively with the physician and interdisciplinary team to enhance the quality of clinical outcomes and patient satisfaction while managing the cost of care and providing timely and accurate information to payers. This role integrates and coordinates utilization management and denial prevention by focusing on identifying and removing unnecessary and redundant care, promoting clinical best practices, and ensuring all patients receive the right care, at the right time, and in the right setting.
Key Responsibilities- Conduct concurrent and retrospective reviews utilizing industry-standard criteria to monitor appropriateness of admissions and continued stays, and document findings based on department policy/procedure.
- Ensure order in chart/EMR and status coincides with the review or CMS rules and regulations for appropriate Level of Care and status on all patients through collaboration with Case Manager.
- Demonstrate thorough knowledge in the application of medical necessity criteria.
- Assess the safest and most efficient care level based on severity of illness, comorbidities, and complications, and the intensity of services being delivered.
- Utilize appropriate payer criteria to provide recommendations to the attending physician.
- Communicate payor criteria and issues on a case-by-case basis with multidisciplinary team and follow up to resolve problems with payors as needed; initiate peer-to-peer when appropriate.
- Contact the attending physician for additional information if the patient does not meet the appropriate medical necessity criteria or in accordance with CMS rules and regulations for continued stay.
- Escalate review timely to physician advisor timely for lack of medical necessity and/or status discrepancies.
- Educate physicians and interdisciplinary team regarding approved criteria practice guidelines, level of care, length of stay, and alternative treatment options.
- Support multi-disciplinary strategies to reduce length of stay, reduce resource consumption, and achieve positive patient outcomes.
- Collaborate with multidisciplinary team members to identify and implement strategies to ensure appropriate utilization and achieve positive patient outcomes.
- Demonstrate knowledge of target length of stay and GMLOS for diagnosis by actively monitoring length of stay timeframe and implementing measures to achieve targets.
- Prevent denials by providing timely clinical reviews to payers for authorization of services provided and complete case review for claim reimbursement.
- Review outlier cases to determine level of care and clinical appropriateness.
- Assist as appropriate in the collection and reporting of financial indicators including length of stay, approved, denied, and avoidable days, and resource utilization.
- Demonstrate skill in communicating with physicians the necessary documentation to demonstrate medical necessity.
- Utilize data to drive decisions related to utilization management for assigned patients, including fiscal and clinical data.
- Responsible for yearly re-education on industry-standard criteria.
- Collect and analyze data to provide information regarding system barriers to care delivery, patient care outcomes, resource trends, and patterns.
- Advocate for, support, and protect the rights of patients. Promptly report any potential compromise of rights to appropriate individual(s).
- Identify quality, infection control, utilization, and risk management issues with referrals to appropriate committee/personnel.
- Continuously pursue excellence in meeting the needs and expectations of all customers (patients, families, interdisciplinary team members, payors, screener, liaisons, and outside services and agencies).
