Utilization Management
CurrentEstablishes and maintains efficient methods of ensuring the medical necessity and appropriateness of all hospital admissionsPerforms concurrent reviews for patients to ensure that extended stays are medically justified and are so documented in patient's medical records.Establishes and maintains rapport with physicians & clinical staff to ensure adequate, accurate documentation of patient.Performs retrospective review/analysis for the appropriateness, effectiveness and efficiency of services.Works effectively with the medical staff to ensure quality and timely physician reviews are conducted. Conducts admission reviews. Information is organized and presented in a manner which facilitates third party payor pre-certification procedures.Obtains and documents admissions diagnosis from attending physician in a timely manner. Advises physician or any third party payors requiring direct contact from a physician for admission reviews.Participates in pre-certifications for admissions with third party payers. Conducts concurrent and extended stay reviews. Conducts the reviews on the appropriate day or at a specified time, if applicable. Demonstrates a remarkable insight and ability in presenting clinical data to third party payors.Prepares and submits appeals to thirdparty payors within required timeframe. Written appeals are concise,encompasses a wide variety of information.Submits discharge clinical to insurance providersObtain signatures from patients (Medicare Rights Form) Complete Medicare AuditsInput data via Midas to reflect accuracy of daily census Attend Treatment Team Meetings & Denial Meetings Completes Pre-Authorization for Outpatient Provides administrative duties such as scanning and getting Medicare certifications signed Conducts insurance pre-cert where insurance requires. Completes Managed Care Form and distributes appropriately. Including diligence in conducting precerts with the appropriate managed care company.