Job Information
Trinity Health UR Coordinator RHIT/LPN in Livonia, Michigan
Employment Type:
Full time
Shift:
Description:
RHIT
Does not require RN
• Reviews assigned medical records in a timely manner for admission, concurrent or retrospective review using InterQual / MCG criteria to determine appropriate level of care.
• Follows the hospital Utilization Review Plan to ensure effective and efficient use of hospital services.
• Demonstrates competency with MCG and Interqual criteria.
• Analyzes and disseminates appropriate clinical information for payer authorization. Extracts pertinent information and communicates in a succinct fashion to the 3rd party payer. Demonstrates sound clinical judgement that supports IP level of care for appropriate reimbursement to the hospital.
• Demonstrates expertise in providing IS/SI criteria to Third Party Payers to obtain authorization for level of care and/or procedures for initial admission, concurrent or retrospective reimbursement.
• Contacts internal physician advisor on cases that do not meet established guidelines for admission or continued stay.
• In the event of an inpatient denial by the payer, obtains further documentation from the physician to support an IP level of care.
• Initiates and coordinates Peer to Peer discussions with physician and payer as warranted.
• Obtains authorizations as required for reimbursement from appropriate Third-Party Payor.
• Works with the Case Managers to obtain hospital to hospital transfer authorization as needed.
• Monitors the DNFB (discharged but not final billed) list to ensure timely claim filing.
• Communicates to the payer patient discharge date and discharge plan. Mediates between case manager and payer to ensure a seamless transition in care and appropriate post-acute follow-up.
• Provides updated Third-Party payor information to assigned Case Manager for continuity of care.
• Identifies areas of quality concerns, inappropriate use of resources and any other issues that restrict the implementation of hospital, department objectives and refers findings for appropriate follow-up.
• Reviews IP denials with the physician advisor to determine if a case should go to the Appeals Team.
• Assists other departments in the reimbursement process including, but not limited to, changes in inpatient, outpatient and observation status, identification of appropriate surgical status and other interventions needed to reduce patient and hospital liability of financial loss.
• Demonstrates proficiency in using various computer programs required including EPIC, Availity, Word, and Payor Portals.
• Responsible for combining admissions on those cases that are appropriate and communicating to Insurance Verification and Health Information Management.
• Functions as a resource to physician, hospital staff or departments and other ‘customers” of the hospital to assist in complying with the utilization review processes.
• Participates in UR Committee, department staff meetings and ad hoc committees on an as needed basis.
• Participates in review and analysis of outcome data related to UR functions and identification of system and process issues that contribute to denials.
The Utilization Review (UR) Coordinator I colleague is responsible for conducting the utilization review process in accordance with federal and state law, licensure/ accreditation and hospital standards and Third Party payor requirements. The review process includes but is not limited to admission/re-admission review (includes identification of fragmentation of care, combined admissions), pre-certification/re-certification review, data gathering for identified projects, internal audits, retrospective reviews, statistics, coding, billing or verification issues. The UR Coordinator I will be a clinical resource to the UR team and provide leadership in this role based on the RN licensure requirement piece of the position.
ESSENTIAL FUNCTIONS AND RESPONSIBILITIES MAY INCLUDE
Provides leadership and expertise for utilization management processes.
Manages the DNFB list and other UR hold reports to ensure account problems are being resolved and clean claims released timely.
Develops and shares reports as requested.
Manages the clinical review/process for 72-hour reviews as assigned by the HIM department.
Manages the clinical review/process for observation cases over 48 hours and assigns the GZ codes as appropriate.
Completes the UR review and obtains authorization on retrospective cases that the insurance has changed after discharge.
o Reviews assigned medical records in a timely manner for admission, concurrent or retrospective review using InterQual criteria to determine appropriate level of care.
o Exhibits consistent documentation of InterQual criteria using the electronic version of InterQual in Cerner Care Management.
o Follows the hospital Utilization Review Plan to ensure effective and efficient use of hospital services.
o Demonstrates competency with InterQual application with a passing score on annual competency test, Inter Rater Reliability.
o Analyzes and disseminates appropriate clinical information for payer authorization. Extracts pertinent information and communicates in a succinct fashion to the 3rd party payer. Demonstrates sound clinical judgement that supports IP level of care for appropriate reimbursement to the hospital. The UR Coordinator must be knowledgeable of health plan contracts and meet their clinical submission deadlines.
o Demonstrates expertise in providing IS/SI criteria to Third Party Payers to obtain authorization for level of care and/or procedures for initial admission, concurrent or retrospective reimbursement.
o Contacts EHR or internal physician advisor on cases that do not meet established guidelines for admission or continued stay.
- In the event of an inpatient denial by the payer, obtains further documentation from the physician to support an IP level of care.
. Initiates and coordinates Peer to Peer discussions with physician and payer as warranted.
Obtains authorizations as required for reimbursement from appropriate Third-Party Payor.
Mediates and coordinates process between insurance company and hospital clinical staff when a patient requires transfer to another acute care hospital.
Monitors the DNFB (discharged but not final billed) list to ensure the authorization is secured timely and the claim can be released for hospital reimbursement.
Processes all technical and administrative denials for all clinical areas of the hospital and facilitates the appeal process as appropriate.
Communicates to the payer patient discharge date and discharge plan. Mediates between case manager and payer to ensure a seamless transition in care and appropriate post-acute follow-up.
Provides updated third-party payor information to assigned Case Manager for continuity of care.
Identifies areas of quality concerns, inappropriate use of resources and any other issues that restrict the implementation of hospital, department objectives and refers findings for appropriate follow-up.
Reviews IP denials with the appeals nurse to determine appropriate status and reimbursement from payer. Appeal determinations are made at that time.
Assists other departments in the reimbursement process including, but not limited to, changes in inpatient, outpatient and observation status, identification of appropriate surgical status and other interventions needed to reduce patient and hospital liability of financial loss.
Demonstrates proficiency in using various computer programs required including, Power Chart, HealthQuest, various payer portals, etc.
Responsible for combining admissions on those cases that are appropriate and communicating to Insurance Verification and Health Information Management.
Assists with payer specific audits as assigned, i.e. RAC, HDI
Functions as a resource to physician, hospital staff or departments and other ‘customers” of the hospital to assist in complying with the utilization review processes.
Participates in UR Committee, department staff meetings and ad hoc committees on an as needed basis.
Participates in review and analysis of outcome data related to UR functions and identification of system and process issues that contribute to denials.
• Maintains good rapport and cooperative relationships. Approaches conflict in a constructive manner. Helps to identify problems, offer solutions, and participate in their resolution.
• Maintains the confidentiality of information acquired pertaining to patient, physicians, associates, and visitors to St. Joseph Mercy Health System. Discusses patient and hospital information only among appropriate personnel in appropriately private places.
• Behaves in accordance with the Mission, Vision and Values of SJMHS.
• Assumes responsibility for performance of job duties in the safest possible manner, to assure personal safety and that of coworkers, and to report all preventable hazards and unsafe practices immediately to management.
OTHER FUNCTIONS AND RESPONSIBILITIES
Performs other duties as assigned.
REQUIRED EDUCATION, EXPERIENCE AND CERTIFICATION/LICENSURE
Education: Associates Degree in health-related field, nursing preferred.
Experience: Three years recent acute care utilization management experience.
Licensure/Certification: Current RHIT or RN licensure, preferred.
REQUIRED SKILLS AND ABILITIES
Understanding of computers and software in order to collect and report information for required data sources.
Ability to work autonomously with little direction and be accountable for outcomes.
Excellent customer service orientation skills necessary to deal effectively with various levels of hospital personnel, outside customers and community groups.
Our Commitment to Diversity and Inclusion
Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.
Our Commitment to Diversity and Inclusion
Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.
Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.
EOE including disability/veteran
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