Works and completes partial prep, chronologies and full prep as assigned, Reviewed and developed process improvements to increase efficiency and accuracy in the referral management process and ensured compliance with the Department of the Army MEDCOM military treatment facility Access Standards for Active Duty Service Members, Coordinated ongoing training to CRC, WTU/SRC staff, Nurse Case Managers, Medical providers, and Evans Army Community Hospital staff while also serving as a preceptor, trainer and mentor for new UR nurses and CRC staff, Oversaw appropriate management of command approval authority by screening referrals and ADSM request for proper medical outsourcing needs, anticipated cost/benefits and/or need to defer to DCCS for additional review, Work with the doctors, and other interdisciplinary health team to ensure patient's safe discharge, Coordinates with the insurance companies to ensure that medical services provided are covered, Assist with patients education, and provides them with resource information, Lead interdisciplinary daily discharge rounds of all patients on assigned unit, Identify high risk patients and work together with other interdisciplinary healthcare team to ensure that patients are not being delayed for their services, Perform utilization reviews for all commercial insurance and all Medicare patients assigned, to ensure that patients meet admission criteria to continue to be in an acute care facility. Reviewed medical records to determine approvals or denials for length of hospital stay based on Interqual criteria. Acted as fill in manager during vacations and absences of manager, Involved in every aspect of the utilization process of cardiology/Oncology Treatment regiments including authorization Requests, referrals, approvals and case preparation for medical review, request and review of medical records, Establish and maintain professional relationships with providers office and staff to ensure operational flow of authorizations and referrals.
Collaborates closely with the Medical Director for complex cases. Identify, evaluate, and initiate case management on patients based on diagnosis/ referrals to Case management/Disease Management Programs. Contacting members both inpatient and after discharge to addressing any needs, and refereing to various health care services to include PCMH program for continuity of care once discharge home.
Answered a busy phone line to educate and explain treatments ordered, Spoke with insurance agents regarding ICD-9 and CPT codes, Collected documentation from numerous providers to add to patient medical history chart. Act as a liaison between the case manager and the provider/injured worker and all other parties to the claim. Documents review information in computer.
Ensures that documentation is clear, concise and meets established specification. Concurrent review and analysis of EMR documentation.
All rights reserved. Denial letters based on need. Communicates results to claims adjusters. Developed standard of practice and competencies for telephone triage and supervised assigned staff.
Performed utilization review activities for Medipass population. Obtains and reviews necessary medical reports and subsequent treatment plan requests to conduct. Provides authorizations and/or denials based on clinical documentation review and medical necessity. – Updated 1,239 medical records. The services that utilization review nurses provide to insurance companies, medical facilities, and patients help in keeping the healthcare industry free of any problems.
Utilized multiple computer programs for data entry. Participated in weekly case review with medical director via phone conference. Oversight of patient care and medical needs via AHCCS standards, Ensure patient transfers are appropriately handled by facilities and their staff, Coordinate all discharge planning activities, Evaluate charts of patients to make sure they meet inpatient criteria per facility standards. Some areas of responsibility included the management of immunizations; routine care; medication refills; referral to specialty clinics; assisting with minor procedures; scheduling; depo-medrol clinic; blood draws and patient education. Responsible for the coordination of managed care patients, tracking appropriate utilization of services. Dealt one on one with numerous doctors and patients daily regarding medical treatments. Communicates with team to review issues/concerns to ensure that there is appropriate work flow, communication and documentation on each file. Initiate discharge planning and readmission prevention plan when applicable. Acted as team lead for remote home based employees providing support and answer questions as appropriate. Represented Utilization Review Department on various committees within SCF and with external partners. Communicated with providers concerning authorization or noncertification of treatment. Click here to read more. Reviews patients' records and evaluates patient progress. Ensures appropriate and cost-effective healthcare services to patients. Conducted OASIS Review to assess appropriateness of documentation for 485 document preparation and ICD-9 Diagnosis Coding, Verified compliance with Agency Policy and Procedure, State, JCAHO, and Hem 11 Guidelines, Managed various insurance audit reviews and subpoena audits for payer inquires, Conducted Medicaid/MediCal care management pre-authorization an treatment authorization requests, Conducted Peer Review preparation, facilitated peer review meetings, and assessed data collection of review findings, Trained and oriented new staff members in learning OASIS documentation procedures, Attended conferences to refine skills for OASIS correlation with ICD-9 coding, Prepared reports and documentation for monthly board meetings, Prepared and submitted monthly IPA reports for delegation audits, Provided supervision in operating an IPA/POD, Monitored and insured productivity and performance, Reviewed NJ Choice and PCA tool for members to decipher medical necessity, Analyzed member records to ensure compliance with government and insurance company reimbursement policies, Determining member review dates according to established diagnostic criteria, Maintained utilization review logs as needed and created reviews to send to medical director, Perform administrative duties; create spreadsheets to log daily activities and other documents as assigned, Ensure effective care being delivered through the use of nationally recognized criteria, Analyze appropriate medical benefits are applied to services reviewed for medical necessity, Serve as liaison between members, providers, benefits and customer service team, Collaborate with Medical Director and Director of Medical Management in reviewing clinically complex patients, Refer cases as necessary to case management to assist in management of catastrophic patients, Identify, initiate and perform discharge planning on clinically complex patients effectively decreasing readmissions. Review physician documentation and medical records to determine if proposed treatment plan is medically necessary and appropriate per medically accepted clinical review criteria. Provided hospital pre-certification and concurrent medical record reviews to determine appropriateness of admissions, procedures and length of stays. Discharge planning, case management, care management, conducting disease management programs and appropriate referrals to disease management programs.
Review initial admission information to provide clinical information to providers for utilization and payment. Work with Medical Director in determining if hospitalization is needed and if client is appropriate for transfer to Rehab or Skilled Nursing Facilities. Worked with Amisys, TruCare and RightFax software. Participated in multi-disciplinary patient case management at the clinic level. Performs utilization review in accordance with all state mandated regulations.
– Contacted average of 10 insurance companies each week. Utilization of health plan protocol, CMS, Milliman, and Hayes Criteria as resources for documentation for appropriateness and standard of care. Adept at efficiently allocating medical resources while ensuring that each patient is treated fairly. Advanced nursing work to assure the reconsideration and corrective action processes for Medicaid Nursing Facilities in accordance to state rules, regulations, and written policies and procedures.
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