General Summary of Position
Reviews and evaluates external denials for medical necessity. Coordinates and monitors the preventive denial and appeals process. Collaborates with the physician, nurse manager, and other members of the health care team to meet individualized patient outcomes. Performs pre-admission, concurrent, and retrospective medical record reviews based on approved screening criteria, knowledge of insurance coverage, and communication with the third-party payers. May assist the manager in managing the daily departmental operations with the goal of maintaining adequate staffing levels and efficient workflow. May act as a resource and mentor to the Utilization Review staff.
Primary Duties and Responsibilities
Completes appeal process for denied days for medical necessity that meets Interqual criteria, or appear to be clinically justified.Completes evaluation of all external denials for medical necessity received by the hospital.Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards and safety standards. Complies with governmental and accreditation regulations.Coordinates decision making regarding the feasibility of initiating an appeal for each external denial for medical necessity.Develops medical summaries of denied cases for review by hospital administration and for possible legal/Maryland Insurance Administrative (MIA) action, where indicated.Identifies and implements strategies to avoid denials and improve efficiency in delivery of care through review and examination of denials.Identifies system delays in service to improve the provision of efficient and timely patient care. Identifies process issues related to the concurrent Case Management system, including appropriate resource utilization and identification of avoidable days.Maintains records of concurrent and retrospective denial activity in conjunction with Case Management support staff. Monitors and tracks denials and appeal results, and coordinates information with Patient Financial Services (PFS). Reports data to the Director and Operations Review Committee.Meets with attending physicians and Physician Advisor, as appropriate, to clarify or collect information in the process of development of appeal letters.Participates in meetings and on committees and represents the department and hospital in community outreach efforts as required.Participates in the educational process for physicians and hospital staff to address issues that impact the number and type of denials. Serves as a resource to all staff in areas of utilization review/management.Utilizes and analyzes current medical/clinical information as well as medical record information to complete appeal letters.May interact with and assist third party payer reviewers to facilitate appropriate care and ensure payment of services. Performs concurrent and retrospective reviews telephonically as required. Completes all forms and documentation necessary to support appropriate utilization of resources.May utilize research methods to collect, tabulate, and analyze data in collaboration with the medical staff, and hospital performance improvement initiates. Implements strategies to correct or modify trends seen through data analysis and outcome monitoring.May serve as a resource to all staff in areas of utilization review/management. Educates members of health care team through in-services, staff meetings, orientation and formal educational offerings.May manage the department in the Managers absence. Keeps Manager informed about issues related to staffing and problem areas. Keeps Manager informed about issues related to quality, risk, patient/family issues and concerns, allocation of resources and vendor/payer issues. Oversees the orientation of new UR Coordinators by establishing the plan and monitoring progress in conjunction with other staff, as necessary. Assists the Manager in monitoring performance issues. Contributes to the performance evaluation process by providing feedback to the Manager and assisting the creation of professional development plans for UR Coordinators. Minimum Qualifications
Education
- Valid RN license in the State of Maryland required and
- Bachelor's degree in Nursing preferred
Experience
- 5-7 years Clinical experience. 5 years experience in utilization management and appeals decision and writing required and
- 5-7 years Experience in utilization management and appeals decision and writing and case management quality management or discharge planning experience. preferred
Licenses and Certifications
- Certification in Utilization Review, Case Management, and Health Care Quality Upon Hire preferred and
- If MFM, Maternal Fetal Medicine (MFM) coding and billing yearly seminars Upon Hire preferred and
- RN - Registered Nurse - State Licensure and/or Compact State Licensure in the State of Maryland Upon Hire required
Knowledge, Skills, and Abilities
- Excellent verbal and written communication skills.
- Working knowledge of word processing software applications preferred.
Why MedStar Health?
At MedStar Health, we understand that our ability to treat others well begins with how we treat each other. We work hard to foster an inclusive and positive environment where our associates feel valued, connected, and empowered. We live up to this promise through:
- Strong emphasis on teamwork-our associates feel connected to each other and our mission as an organization. In return, our effective team environment generates positive patient outcomes and high associate satisfaction ratings that exceed the national benchmark.
- Strategic focus on equity, inclusion, & diversity-we are committed to equity for all people and communities. We continue to build a diverse and inclusive workplace where people feel a sense of belonging and the ability to contribute to equitable care delivery and improved community health outcomes at all levels of the organization.
- Comprehensive total rewards package-including competitive pay, generous paid time off, great health and wellness benefits, retirement savings, education assistance, and so much more.
- More career opportunities closer to home-as the largest healthcare provider in the Baltimore-Washington, D.C. region, there are countless opportunities to grow your career and fulfill your aspirations.
About MedStar Health
MedStar Health is dedicated to providing the highest quality care for people in Maryland and the Washington, D.C., region, while advancing the practice of medicine through education, innovation, and research. Our team of 32,000 includes physicians, nurses, residents, fellows, and many other clinical and non-clinical associates working in a variety of settings across our health system, including 10 hospitals and more than 300 community-based locations, the largest home health provider in the region, and highly respected institutes dedicated to research and innovation. As the medical education and clinical partner of Georgetown University for more than 20 years, MedStar Health is dedicated not only to teaching the next generation of doctors, but also to the continuing education, professional development, and personal fulfillment of our whole team. Together, we use the best of our minds and the best of our hearts to serve our patients, those who care for them, and our communities. It's how we treat people.
MedStar Health is an Equal Opportunity (EO) Employer and assures equal opportunity for all applicants and employees. We hire people to work in different locations, and we comply with the federal, state and local laws governing each of those locations. MedStar Health makes all decisions regarding employment, including for example, hiring, transfer, promotion, compensation, benefit eligibility, discipline, and discharge without regard to any protected status, including race, color, creed, religion, national origin, citizenship status, sex, age, disability, veteran status, marital status, sexual orientation, gender identity or expression, political affiliations, or any other characteristic protected by federal, state or local EO laws. If you receive an offer of employment, it is MedStar Health's policy to hire its employees on an at-will basis, which means you or MedStar Health may terminate this relationship at any time, for any reason.