The Woodlands, TX30+ days ago
SKILLS AND ABILITIES Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through ongoing skills, competency assessments, and performance evaluations Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles Progressive knowledge of InterQual Level of Care Criteria or Milliman Care Guidelines and knowledge of local and national coverage determinations Recent work experience in a hospital or insurance company providing utilization review services Knowledge of Medicare, Medicaid, and Managed Care requirements Progressive knowledge of community resources, health care financial and payer requirements/issues, and eligibility for state, local, and federal programs Progressive knowledge of utilization management, case management, performance improvement, and managed care reimbursement Ability to work independently and exercise sound judgment in interactions with physicians, payers, and health care team members Strong assessment, organizational, and problem-solving skills Maintains level of professional contributions as defined in Career Path program Understands and applies federal law regarding the use of Hospital Initiated Notice of Non-Coverage (HINN), Ambulatory Benefit Notice (ABN), Important Message from Medicare (IMM), Medicare Outpatient Observation Notice (MOON), and Condition Code 44 (CC44). Service Essential Function Pro-actively participates as a member of the interdisciplinary clinical team to confirm appropriateness of the treatment plan relative to the patient's preference, reason for admission, and availability of resources Participates in daily Care Coordination Rounds and identifies and communicates barriers to efficient utilization Reviews H&Ps and admitting orders of all direct, transfer, and emergency care patients designated for admission to ensure compliance with CMS guidelines regarding appropriateness of level of care Identifies potentially unnecessary services and care delivery settings and recommends alternatives, if appropriate, by analyzing clinical protocols Escalates appropriate cases to the Physician Advisor (or services) for appropriate second level review, peer-peer discussions, and payer denial- appeal needs Consults with physician advisor as necessary to resolve progression-of-care barriers through appropriate administrative and medical channels.