Utilization Management Consultant

at  Genesis HealthCare System

GENESIS HEALTHCARE SYSTEM

In order to fill our Mission of serving our community by helping each person achieve optimal health and well-being by providing compassionate, exceptional, and affordable healthcare services, all employees of Genesis HealthCare System must be committed to living the Genesis Mission and Genesis values of Compassion, Excellence, Integrity, Team, and Innovation. All employees must regard themselves as an ‘owner’ of Genesis and keep our patients at the center of everything we do - always.
Position Details:
Work Shift:
Day Shift (United States of America)
Scheduled Weekly Hours:
40
Department:
Utilization Management
Overview of Position:
Acts as part of a multidisciplinary team including Genesis Financial and Reimbursement Services, providers, payers, and discharge planners to ensure the patient’s progress across the continuum is efficient, with quality patient care, while promoting cost effective resource utilization. The position is responsible for maintaining hospital compliance with the Quality Improvement Organization (QIO) and CMS guidelines. In addition the position provides case review information to third party payers, assists in the denial and appeals process, and assesses quality, identifying and reporting potential risk management issues. Utilization Management analyzes and trends information and data in order to optimize efficiency of operational systems.

QUALIFICATIONS

1. BSN or Bachelor’s degree in a health-related field or ADN with 20 years of experience.
2. Current Ohio RN licensure.
3. Three (3) years of registered nursing experience in the hospital or home care setting required.
4. Ability to perform data analysis and to utilize computer systems to record and communicate information to other services.
5. Excellent verbal and organizational skills to facilitate the case management process and ensure patients and customers are served promptly and with respect.
6. Must demonstrate decisiveness and attention to detail.

WORKING CONDITIONS/PHYSICAL REQUIREMENTS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
1. Must be able to hear, speak, see and to coordinate motor skills.
2. Must be able to climb, lift 25 pounds, stoop and bend.
3. Ability to read, write and utilize manual and computerized systems of documentation
4. Ability to collect data, analyze and interpret findings, set priorities and carry out established plan. 5. Must tolerate reading a significant amount of information in a relatively short period of time.
6. Ability to work under stress both with and without supervision.
This description reflects in general terms the type and level of work performed. It is not intended to be all-inclusive, nor portray the specific duties of any one incumbent.
Thank you for your interest in employment at Genesis. Genesis is committed to being an equal opportunity employer. Selection of applicants for employment is based only on qualifications and the requirements of a specific job

1. Communicates in a timely manner to third-party payers to seek reimbursement certification.
2. Applies approved utilization acuity criteria to monitor appropriateness of admissions, levels of care, and continued stays. Identifies patients classified incorrectly and collaborates with physicians to rectify the status.
3. Facilitates PA-to-PA reviews in cases where there is disagreement about medical necessity. Refers cases and issues to physician advisor in compliance with department procedures and follows up as indicated.
4. Interacts with physicians on patient care, resource utilization & observation issues. Actively involves the physicians in order to prevent delays and improve patient outcomes concurrently.
5. Addresses and resolves system problems impeding diagnostic or treatment progress. In addition, proactively identifies and resolves delays and removes obstacles to discharge.
6. Works with various payer portals or Ohio MITS portal for authorization of services.
7. Timely and accurate maintenance of documentation in the Observation Log.
8. Serves as a clinical resource for departments to ensure reimbursement optimization through essential documentation and coding.
9. Organizes and follows through with all aspects of denial/appeal activities in a timely manner on assigned cases. Investigates and analyzes personal denial rates. Actively implements initiatives to prevent and decrease personal denial/appeal levels.
10. Completes all required documentation; records InterQual for appropriate med necessity, trends variances, completes indicators, occurrences, delays and referrals on assigned cases. Provides solutions and interventions as necessary.
11. Remains competent in use of Epic for documentation; remains up-to-date on all optimizations; is competent in running reports that govern daily workloads.
12. Maintains hospital compliance with the Quality Improvement Organization (QIO) and CMS guidelines.
13. Communicates discharges to appropriate care managers (payer or community)
14. Reviews work queues daily and impacts cases within 10 business days.
15. Behavioral Health UR: In addition to above, completes prior authorizations on medications ordered at discharge.
16. Behavioral Health UR: Attends adult and adolescent treatment team meetings.
17. Obs UR: In addition to above (non-BH), reports promptly to Obs MDRs.
18. Obs UR: Verifies documentation of or delivers and documents the Observation Notification.
19. Obs UR: Assists with distributing Medicare rights letters during high inpatient census
20. ED UR: Screens for appropriateness of admission versus lower level of care (community level of care; reviews for correct patient classification (e.g. inpatient versus observation, etc.), based on InterQual criteria;
21. ED UR: Works with admitting department, bed coordinator and nursing campus supervisor to facilitate proper Unit placement along with proper status of patients admitted out of the ER or admitted to Genesis HealthCare System from another acute care hospital.
22. ED UR: Collects data related to CDI and department performance measures as needed.
23. ED UR: Works with ER physicians, staff and ED High Risk Care Coordinator (EDHRCC) to assist with follow-up on as many ER frequent- visit patients as possible. Assists with creating appropriate care plans and documents these in EPIC.
24. ED UR: Assist EDHRCC with facilitating appropriate follow-up on patients that cannot get appropriate follow-up appointments with physicians.