Utilization Review/Clinical Docu. Spec./ RN Job Opening

Responsible for improving the overall quality and completeness of clinical documentation. Facilitates modifications to clinical documentation practices through extensive interaction with physicians, allied medical practitioners, nursing staff, other patient caregivers and coding staff to ensure that appropriate reimbursement is received for the level of service rendered to all patients with a DRG-based payor (Medicare, Medicaid, Other). Ensures the accuracy and completeness of clinical information used for reporting, including physician and hospital outcomes. Educates all members of the patient care team on an ongoing basis.

To perform review activities relative to assuring appropriate utilization of hospital services, assessing, facilitating and obtaining appropriate resources for identified continuing care needs. Assessing patients, beginning with the admission review, to determine medical necessity, appropriate level of care and obtaining appropriate authorization for procedures both planned and emergent on an outpatient or inpatient basis.

• Assists in screening process, making referrals, interacting with integrated review nurses and care coordinators to ensure continuity of patient care as needed.
• Conducts follow-up reviews of clinical documentation to ensure that requested clarifications have been recorded in the medical record.
• Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes.
• Facilitates concurrent documentation from all disciplines (physicians and assistants, care coordinators, nurses, discharge planners, etc.) to capture best practice Quality Indicators for specific improvement projects (currently Heart Failure, Acute Myocardial Infarction, Pneumonia, and Surgical Infection Prevention) to support the CMS/TJC Hospital Quality Alliance, the Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU), and the Physician Quality Reporting Initiative (PQRI) requirements.
• Improves overall quality and completeness of clinical documentation contained in the medical record by performing admission/continued stay reviews using Compliant Documentation Program Management (CDMP) guidelines.
• In cooperation with Coding, Compliance, and Quality Management, educates all caregivers on compliant documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies. Reviews clinical issues with coding staff to assign a working DRG.
• Process discharges by updating the DRG Worksheet and Quality Worksheet to reflect any changes in status, procedures/treatments, and conferring with physicians to finalize diagnoses and documentation of quality measures.
• Reviews medical records of current hospital inpatients and facilitates modifications to clinical documentation to ensure that appropriate reimbursement is received for the level of service rendered to all patients with a DRG based payor (Medicare, Medicaid, Other payors as specified).
• Communicates level of care information and treatment plans to insurance companies, managed care organizations, home health and/or long term care facilities. Confers with patients regarding insurance benefits as it relates to the necessary level of care and/or discharge planning needs.
• Reviews medical records of patients currently hospitalized to evaluate level of care, to assess continued need for acute care and to assess potential need for community resources after discharge; to confer with physicians, nurses, and other appropriate hospital personnel to determine and document appropriateness of patient admission and continued need for hospital care; collect data as appropriate.
• Reviews surgical schedules for planned outpatient surgical procedures to assure prior authorization or pre-certifications are obtained prior to a procedure.
• Performs other related duties as assigned.

Minimum Requirements

Education:

• Graduation from an accredited school of nursing - required
• Bachelors Degree - preferred

Experience:

• Recent clinical experience in a hospital setting including three years medical-surgical nursing experience, or four years recent medical-surgical clinical experience - required
• Utilization review,coding experience, or CDI experience - minimum of 2 years preferred
• Good critical thinking skills, able to assess, evaluate, and teach. Flexible, with a working knowledge of all areas of adult medicine.
• Working knowledge of statistical process controls and computer databases.
• Strong analytical and communication skills.
• Good interpersonal skills.