• Responsible for concurrent review of both inpatient and outpatient services in accordance with the utilization program which meets the requirements of JCAHO, PRO/W, Medical Staff Bylaws and third party payor contracts.
• Facilitates the achievement of consistent clinical outcomes by concurrently assessing quality concerns and referring to appropriate individuals in accordance with FHS policy.  Collects data and conducts focused reviews/studies.
• Works collaboratively with the attending physician(s) to provide effective and efficient health care services that best serve the needs of the patient.  Refers questionable cases regarding appropriateness of services to the attending physician and/or physician advisor.
• Prepares and issues admission denials and decertification notices for termination of benefits in accordance with PRO/W, JCAHO and FHS standards.
• Attends interdisciplinary discharge planning rounds and patient/family conferences as scheduled.  Plans and implements therapeutic teaching strategies and support for post-discharge care.  Works pro-actively with social services and the physician to facilitate the patient's discharge plan.
• Performs data analysis for interpretation and presentation to medical staff, hospital staff and administration.
• Participates in continuing physician education and care management staff development activities.  Serves as resource to physicians and hospital staff as well as patients and their families regarding quality and Utilization Management issues.
• Provides data input to administration to assist in contract development and/or other programs as needed.
• Represents care management services as a liaison to internal and external bodies.  This includes, but is not limited to:  Patient Access, Financial Account representatives, Regional Business Office, and third party payors.
• Monitors third party payor denials with finance department and works with business office in preparing written responses to ensure optimum reimbursement.

• Must be a graduate of an accredited medical record technology/medical record administration program and/or school of nursing. 

Experience:

•   Requires a minimum of three years of healthcare-related work experience, preferably in utilization or quality review in an acute care or outpatient setting.

• None required.

• Demonstrates a commitment to service, organization values and professionalism through appropriate conduct and demeanor at all times.
• Adheres to and exhibits our core values:
  Reverence: Having a profound spirit of awe and respect for all creation, shaping relationships to self, to one another and to God and acknowledging that we hold in trust all that has been given to us.
  Integrity: Moral wholeness, soundness, uprightness, honesty and sincerity as a basis of trustworthiness.
  Compassion: Feeling with others, being one with others in their sorrows and joys, rooted in the sense of solidarity as members of the human community.
  Excellence: Outstanding achievement, merit, virtue; continually surpassing standards to achieve/maintain quality.
• Maintains confidentiality and protects sensitive data at all times.
• Adheres to organizational and department specific safety standards and guidelines.
• Works collaboratively and supports efforts of team members.
• Demonstrates exceptional customer service and interacts effectively with physicians, patients, residents, visitors, staff and the broader health care community.

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