Patient Care Utilization Analyst
2 weeks ago
The Utilization Management Specialist (LPN) is responsible for evaluating patient records to assess the validity of hospital admissions, treatments, and the appropriate level of care required.
This role utilizes advanced UM software algorithms to analyze critical clinical data points, aiding in recommendations for patient status and care levels.
Educational Requirements:
Completion of a state-approved Licensed Practical Nurse program or equivalent registered nurse coursework recognized by the Board of Nursing is required. A Bachelor of Science in Nursing or a related field is preferred.
Licensure and Certification:
Must possess a valid LPN License from the State of Oklahoma. ACM/CCM certification is preferred.
Experience:
A minimum of three years of relevant experience in an acute care environment is required. Familiarity with electronic health records is preferred.
Skills and Competencies:
- Strong organizational and time management abilities with a focus on prioritizing multiple tasks.
- Excellent interpersonal, written, and verbal communication skills.
- Proficient in data analysis to derive insights and develop knowledge.
- Detail-oriented with a strong focus on numerical data examination.
- Proficient in Microsoft Word, Excel, and Access for report preparation and correspondence.
Key Responsibilities:
- Monitor patient admissions and conduct initial reviews within 24 hours of admission, continuing assessments as necessary based on length of stay and utilization review guidelines.
- Provide pre-admission status recommendations in emergency or elective procedure settings, communicating guidance to providers based on available data.
- Maintain comprehensive knowledge of payer guidelines and processes for authorization to prevent reimbursement losses, including managing concurrent and pre-bill denials.
- Ensure all benefits, authorization requirements, and collection notes are documented accurately to facilitate timely reimbursement and avoid denials.
- Collaborate effectively with physicians, nursing staff, and other members of the multidisciplinary care team to ensure timely and appropriate claims management.
- Facilitate precertification and payer authorization processes, ensuring proper authorization is secured prior to discharge for observation and inpatient stays.
Decision-Making:
Responsible for executing non-routine procedures under varying conditions, following general instructions from supervisors.
Working Relationships:
Engage directly with patients and customers, as well as internal stakeholders through both telephone and face-to-face interactions. Collaborate frequently with healthcare professionals and staff at the Director level or above.
Additional Information:
This document outlines the essential functions of the role and the physical demands required. It is not an exhaustive list and does not restrict the assignment of additional duties.
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