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Clinical Nurse Specialist
2 months ago
Utilization Management Overview
Utilization Management (UM) involves the assessment of the medical necessity, appropriateness, and efficiency of healthcare services, procedures, and facilities in accordance with the relevant health benefits plan.
Prior authorization is a critical component that enables payers, particularly health insurance providers, to oversee healthcare costs by evaluating the appropriateness of services before they are rendered, utilizing evidence-based criteria or guidelines. A robust utilization management process can significantly minimize payment denials.
Role of Clinical Documentation Specialists
The role of Clinical Documentation Specialists is to enhance the accuracy of physician documentation within patient medical records, ensuring that the severity of illness, expected risk of mortality, and complexity of care are appropriately represented.
This position necessitates extensive collaboration with physicians, nursing staff, support personnel, and medical records coding staff.
Employee Insurance Liaison Responsibilities
At Meadville Medical Center, a dedicated staff member collaborates with Human Resources, Highmark Liaison, Medical Director, and employees to manage self-funded insurance processes. Employees must request waivers for out-of-network medical procedures, which are then reviewed by the liaison in conjunction with the Medical Director. If approved, the liaison will inform both the employee and the Highmark Liaison.
Medical necessity criteria, urgency, and patient medical history will be evaluated, and the decision will be communicated to the employee. If the outcome is unfavorable, an appeal can be made to Human Resources.
In cases where the established process is not adhered to, and an employee receives a bill, the liaison will review the services rendered, consult with the Medical Director, and determine if an exception to out-of-network rules is warranted.
Key Attributes
Ideal candidates should be:
- Inquisitive and detail-oriented, actively seeking innovative solutions and answers to complex questions.
- Meticulous in their attention to detail.
- Committed to continuous professional development.
Utilization Management Process
Utilization management serves as a strategy for managing both cost and quality under the latest reimbursement guidelines. Key responsibilities include:
- Reviewing precertification requests for medical necessity and referring complex cases to the Medical Director.
- Conducting concurrent reviews of clinical information to determine the appropriateness of extending inpatient stays.
- Establishing effective relationships with colleagues, support staff, clients, and healthcare providers.
Clinical Documentation Specialist Duties for Inpatients
Successful candidates will possess advanced clinical expertise and a comprehensive understanding of complex disease processes, with significant experience in inpatient settings. Responsibilities include:
- Conducting regular reviews of patient records to support accurate DRG assignments upon discharge.
- Formulating queries to address missing or conflicting documentation.
- Providing ongoing education to physicians and healthcare providers on the importance of precise clinical documentation.
- Utilizing coding nomenclature and demonstrating knowledge of ICD-10 classifications.
- Participating in the analysis of statistical data to identify opportunities for improvement.
- Collaborating with coding professionals to ensure the accuracy of diagnoses and procedures.
- Acting as a resource for interdisciplinary teams to promote coordinated patient care.
Department Goals
The department is dedicated to:
- Enhancing the quality of care and patient outcomes.
- Promoting cost-effective medical practices.
- Preventing unnecessary hospitalizations.
- Reducing lengths of observation and inpatient stays when appropriate.
- Ensuring continuity of care.
- Facilitating appropriate levels of care for patients.
- Engaging in rounding on nursing floors.
- Collaborating with Health Information Management on coding issues.
- Providing guidance to precertification staff.
- Identifying alternative resources and demonstrating creativity in case management.
- Maintaining accurate records of all communications and interventions.
Minimum Qualifications
Applicants must possess:
- Proof of successful completion of educational requirements for board-certified registered nurses as defined by state regulations, along with valid licensure in good standing.
- A minimum of 5 years of experience as a Registered Nurse.
- The ability to read, analyze, and interpret various documents, reports, and regulations.
- BLS certification is required.
- Certification for UM nurses and CDI specialists is encouraged.
