Utilization Review Specialist

ABOUT SHERIDAN MEMORIAL HOSPITAL

Sheridan Memorial Hospital is a progressive, state-of-the-art facility nestled beneath the Big Horn Mountains in beautiful Northeast Wyoming. Founded over 100 years ago, Sheridan Memorial is licensed for 88 beds with over 60 physicians who provide primary medical care and specialty care in more than 15 areas. We are proud of our more than 700 employees who provide personalized, patient-centered care in a healing environment. When people think of excellent healthcare, they think of Sheridan.

JOB SUMMARY

The performance of the Utilization Review function on all patients presenting for hospitalization to assist in identifying patients appropriate for admission to inpatient, observation, or other patient care status. Conducting continued stay review evaluating the medical necessity, appropriateness and efficient use of health care services of all hospitalizations, inpatient or outpatient. Collaborating with the physicians, health care team and care coordinator to optimally certify the level of care and facilitate the patient’s movement thru the continuum of care as appropriate. The Utilization Review Specialist is also integral in the development and implementation of electronic quality metric data analysis and reporting.

ESSENTIAL JOB FUNCTIONS

• Demonstrates expertise in the application of InterQual criteria.
• Review of clinical data for ED admits, making level of care recommendation to the ED physician and obtaining any additional clinical information that may assist in level of care determination.
• Manages all direct admits, clarifying level of care orders and performing InterQual screening as appropriate. Acquires additional information if necessary to assist in level of care determination.
• Reviews all requests for changes in status for admission from the PACU, cardiac catheterization area, or any outpatient surgery areas. Applies InterQual criteria to determine appropriateness for level of care requested, consulting with attending physician as necessary.
• Insures operative procedure performed is the operative procedure prior-authorized with the third party payor and communicates any variance.
• Serves as a resource for facilitating patient transfers, including, but not limited to, obtaining or providing clinical information from/to the referring/accepting facility. Performing clinical reviews of all inbound transfers for appropriateness.
• Identification of high-risk social issues and referral to Social Worker or Director of Medical Management as appropriate.
• Proficiency with use of Conditional Codes 44 and W2.
• Monitors use of healthcare resources. Communicates with physicians to assure patient receives diagnostics/evaluations in the proper setting, i.e. inpatient vs outpatient.
• Maintains current knowledge of CMS (Medicare) rules and regulations and conditions of participation.
• Communicates openly with third party payors and works collaboratively with them to avoid concurrent denials.
• Works to manage commercial insurance denials when appropriate independently or with the assistance of third party consultants.
• Collaborates with the care coordinator to ensure appropriate level of care.
• Actively participates in the multidisciplinary team meetings.
• Identifies and documents delays in service.
• Serves as an expert resource to physicians and healthcare staff in the application of InterQual criteria and the use of evidence based practices.
• Conducts initial (admission) reviews at the time of presentation, or within 24 hours, if patient presents during uncovered hours.
• Conducts concurrent review per department policy (every three days for Medicare unless the patient condition changes), and as private payor dictates.
• Conducts observation reviews daily.
• Follows department policy regarding escalation of utilization issues to the Physician Advisor or his/her designee.
• Actively participates in pertinent process improvement events.
• Interprets data and analyzes results using statistical techniques.
• Develop and implement data analysis, data collection systems, and other strategies that optimize efficiency ad quality performance.
• Processing confidential data and information according to appropriate organization and federal guidelines.
• Generate reports from single and multiple systems.
• Train end users on new reports, data collection techniques, and data presentation.
• Collaborate in the facilitation and proficiency of optimizing EMR modules for Infection prevention and quality reporting.

POSITION QUALIFICATIONS

Education / Experience / License and Certifications

• Bachelor’s Degree in Nursing or related field with case management experience, preferred.
• Current unrestricted Wyoming Registered Nurse License, if applicable.
• BLS certification, preferred.
• Minimum 3 years recent hospital based patient care or relevant experience preferred.
• Minimum 3 years Milliman or InterQual experience, preferred.
• HMO, managed care, PPO, Utilization Management/medical management experience preferred.

Sheridan Memorial Hospital is an equal opportunity/Affirmative Action employer and gives consideration for employment to qualified applicants without regard to race, color, religion, age, sex, national origin, disability or protected veteran status. If you would like more information about your EEO rights as an applicant under the law, please click here.

Specific demands not listed: Possible exposure to blood and or body fluids / infectious disease / hazardous waste requiring the use of Personal Protective Equipment. Exposure to odorous chemicals / specimens and Latex products.

Pre-employment drug and alcohol screening is required.