Trinity Health UR DOCUMENTATION SPECIALIST in Maywood, Illinois
Performs utilization review and certifies patient stays by analyzing patient medical records and accompanying physician documentation. Performs concurrent review for proper patient classification and ongoing need for hospitalization, using appropriate criteria.
Using knowledge of medical necessity and appropriateness of setting as gained through a thorough understanding of milliman and interqual criteria, conducts concurrent utilization review. Applies criteria to all
observation, inpatient admission and extended stay reviews, meeting all timeframes in order to insure certification of all days; contacts physician for cases not meeting criteria to discuss level of care issues, treatment
plan; refers cases not meeting criteria to a physician advisor and follows each case to successful conclusion; reviews caseload to insure all required calls to insurers/third parties are being made; completes
caseload daily and completes utilization review abstract according to guidelines. Captures data from special studies, such as avoidable days. Refers problem cases to appropriate supervisor or physician advisor.
Interacts with insurers, third party payors, and review entities such as EQ Health for Medicaid to relay clinical information and to certify inpatient care for payment. Fulfills all requirements for managed care contracted
review in order to secure reimbursement and bonus dollars.
Records all interactions in department databases and software such as ALLscripts. Prepares trend reports for select ICUs and patient care areas. Develops and conducts competency reviews in areas pertinent to role,
i.e., ur, drug assurance, managed care, and quality screening.
Required:3-5 years of previous job-related experience
Current Registered Nurse License State of Illinois
Other:Recent (within past 3 years) clinical experience is required for candidates without utilization review and documentation experience. On-the-job training in utilization review and documentation improvement is provided to all staff hired into this position.
Job Number: 00108808
Location: Maywood, IL
Organization Name: Loyola University Medical Center
Facility: LUHS-Loyola University Medical Center
Employment Type: Full time