Other - Travel RN - Lansing, MI - $2,346 per week - 26441064 - TravelNurseSource : Job Details

Utilization Review and Clinical Evaluation:

• Review patient medical records, treatment plans, and clinical data to assess the appropriateness of the care being provided and the necessity for continued hospitalization or services.
• Assess the medical necessity of procedures, tests, and treatments to ensure they align with established guidelines and criteria, such as those from the InterQual or Milliman Care Guidelines.
• Evaluate whether the care provided is appropriate, efficient, and meets the standards of care based on clinical evidence.

Collaboration with Healthcare Providers:

• Collaborate with physicians, case managers, and other healthcare professionals to ensure that patient care plans are appropriate and cost-effective.
• Communicate with healthcare teams to discuss any discrepancies or concerns regarding the utilization of resources, care plans, or treatment goals.
• Provide recommendations or alternative care options to improve patient outcomes and optimize resource utilization.

Insurance and Payer Interaction:

• Work closely with insurance companies, managed care organizations, and government payers (e.g., Medicare, Medicaid) to review cases for coverage, authorization, and reimbursement.
• Submit necessary documentation and justification to insurance companies to support medical necessity determinations and secure prior authorization for treatments, procedures, or extended hospital stays.
• Resolve any issues related to denied claims or requests for additional documentation to ensure that services are covered by insurance providers.

Monitoring of Length of Stay and Discharge Planning:

• Monitor patient length of stay (LOS) to identify potential delays in discharge and ensure that patients are not staying in the hospital longer than necessary.
• Work with case management teams to develop appropriate discharge plans, ensuring that the patient is ready for discharge and has the necessary resources and follow-up care.
• Identify potential barriers to discharge and collaborate with the interdisciplinary team to address these issues and facilitate a timely discharge.

Compliance and Quality Assurance:

• Ensure that utilization review practices comply with regulatory standards, including The Joint Commission (TJC), Centers for Medicare & Medicaid Services (CMS), and other state or federal regulations.
• Assist with audits to evaluate the efficiency and accuracy of utilization management processes, making improvements where necessary.
• Maintain up-to-date knowledge of healthcare regulations, coding guidelines (ICD-10, CPT), and payer-specific policies to ensure accurate documentation and compliance.

Documentation and Reporting:

• Document findings from utilization reviews in the appropriate systems and ensure accurate record-keeping for insurance purposes and quality improvement efforts.
• Prepare reports on utilization metrics, including patterns in hospital admissions, readmissions, and discharge delays, for management and leadership review.
• Provide detailed, evidence-based rationales for medical necessity determinations and collaborate with the healthcare team to ensure compliance with UR protocols.

Case Review and Decision-Making:

• Perform retrospective and concurrent review of patient cases to determine if the level of care aligns with guidelines and if resources are being utilized efficiently.
• Recommend the appropriate level of care (e.g., inpatient, outpatient, skilled nursing facility) based on clinical findings and guidelines.
• Provide feedback to clinicians and healthcare teams regarding any areas for improvement in care planning or resource utilization.

Education and Training:

• Educate staff and providers on the importance of utilization review processes, medical necessity criteria, and compliance with payer requirements.
• Stay current on the latest healthcare policies, clinical guidelines, and best practices for utilization management.
• Participate in continuing education and training programs related to UR, case management, or quality improvement initiatives.