JOB SUMMARY: Performs initial, concurrent and retrospective medical record review (clinical documentation) to determine medical necessity for acute care admission based on the application of nationally recognized acute care criteria, federal and state mandates and regulatory body requirements.
Reports to Director, Care Management / Utilization Review.
MAJOR DUTIES AND RESPONSIBILITIES: *1. Performs and ensures adherence to state, federal and third party payer certification requirements for initial, concurrent and retrospective medical record review for medical necessity/level of care determination.
*2. Identifies and notifies appropriate staff regarding discrepancy issues with third party payer health insurance coverage/lack of coverage.
*3. Maintains a working knowledge of third party payer health plans, working knowledge of nationally recognized review criteria and its application and state and federal regulations and mandates.
*4. Reviews OP cases, using standard parameters, in order to perform precertification requirements as indicated in third party payer contracts.
*5. Reviews all admission requests for appropriateness of level of care and compliance with third party pre-admission certification requirements, regulatory and standard ambulatory procedures (Pre-approval/precertification).
*6. Requests additional clinical information/documentation when request does not meet medical necessity for level of care requested.
7. Develops and maintains positive relationships between physicians and office staff. Interacts with physicians as needed. Provides information, suggests alternatives and assists in ensuring documentation integrity.
*8. Enters UR data into Utilization Review Epic Module database for tracking and trending audits, billing and reimbursement and Medicare compliance requirements.
*9. Reports serious events and incidents in accordance with established hospital policy and procedure.
10. Attends to and ensures to the utmost integrity of the medical necessity chart review and application of review requirements.
*11. Makes appropriate suggestions and/or recommendations to Manager or Director, Utilization Review to resolve identified issues, streamline processes and improve efficiencies within the department and/or hospital.
12. Acts a resource person for the healthcare team regarding third party payer health plan benefits for transition to next level of care or discharge to home.
13. Treats all internal and external information with strict confidentiality as per HIPPA guidelines and regulations.
14. Notifies care managers/social workers of downgrades from Inpatient to observation.
15. Performs other duties within scope of education/qualifications as requested by department director.
*Denotes essential job functions.
COMPETENCIES AND SKILLS: Demonstrates knowledge of payor practices and regulatory mandates.
Demonstrates exceptional ability to retrieve clinical information from medical chart/documentation.
Demonstrates working knowledge of third party payers and pre-certification process.
Demonstrates the ability to review medical clinical documentation for sustained periods of time with high level of concentration.
Demonstrates the ability to collaborate with other members of the healthcare team and providers in a positive, professional, progressive and assertive manner.
Demonstrates excellent written and oral communication skills.
Demonstrates computer literacy.
EDUCATION AND/OR EXPERIENCE:
RN license or eligible for licensure in the state of Pennsylvania required. Bachelors degree in nursing preferred.
Minimum 3 to 5 years acute care experience required.
Experience with Utilization Review preferred.
WORKING CONDITIONS/PHYSICAL DEMANDS: Work is typically performed in an office or clinical environment. Must allow for 7 days per week, 24 hour per day scheduling. Weekend, holiday rotation, and on call may be required. Flexibility in site or work. Travel may be required.
Geisinger Health System is an integrated health services organization widely recognized for its innovative use of the electronic health record and the development of innovative care delivery models such as ProvenHealth Navigator and ProvenCare. As one of the nations largest health service organizations, Geisinger serves more than 3 million residents throughout 45 counties in central, south-central and northeast Pennsylvania, and also in southern New Jersey with the addition of AtlantiCare, a National Malcolm Baldridge Award recipient. The physician-led system is comprised of approximately 30,000 employees,including nearly 1,600 employed physicians, 12 hospital campuses, two research centers and a 510,000-member health plan, all of which leverage an estimated $8.9 billion positive impact on the Pennsylvania economy. Geisinger has repeatedly garnered national accolades for integration, quality and service. In addition to fulfilling its patient care mission, Geisinger has a long-standing commitment to medical education, research and community service. For more information, visit , or follow the latest Geisinger news and more on and .
** Does not qualify for J-1 waiver. We are an Affirmative Action, Equal Opportunity Employer Women and Minorities are Encouraged to Apply. All qualified applicants will receive consideration for employment and will not be discriminated against on the basis of disability or their protected veteran status.