Utilization Payor Specialist Rn

Division:Eskenazi Health

Sub-Division:Hospital

Req :24795

Schedule
:

Full Time

Shift
:

Days

Salary Range:

Eskenazi Health serves as the public hospital division of the Health & Hospital Corporation of Marion County. Physicians provide a comprehensive range of primary and specialty care services at the 327-bed hospital and outpatient facilities both on and off of the Eskenazi Health downtown campus as well as at 10 Eskenazi Health Center sites located throughout Indianapolis.

The Utilization Payor Specialist, RN is responsible for working behind the scenes to maximize the quality and cost of efficiency of health services. This position coordinates pre-certifications, re-certifications, the denial management and appeals process, and initial and concurrent reviews. Through regular reviews and audits, the Utilization Payor Specialist ensures that patients receive the care needed without burdening the health care system with unnecessary procedures, ineffective treatments or lengthy hospital stays.

#EXPRN

• Communicates secondary review decisions determining appropriate patient status provided by secondary reviewer process
• Communicates and negotiates with payers to obtain approvals for the appropriate care level
• Serves as a resource on payor requirements for severity and intensity of service determinations for outpatient and acute inpatient admissions
• Provides timely payor feedback to Case Managers and Social Workers; notifies the Case Manager when additional clinical information may be required that is not currently identified within the electronic medical record or bedside documentation to ensure that services will be approved at the acute level of care as required by the payor
• Ensures pre-certification/authorizations for post-acute services, initial, concurrent reviews, authorizations not obtained by Patient Registration/Admitting or the doctor's office and clinics for direct admissions and procedures
• Reviews patient admission for appropriateness and type; refers case to Medical Director/department leadership for review and course of action when case fails to meet admission standards
• Coordinates and facilitates the most accurate and appropriate patient status for care across the continuum
• Actively communicates and documents payor issues and concerns regarding the initial level of care, continued stay, denials and discharge plans to the Medical Director/department leadership as appropriate
• Supports the denial management process and participates in tracking and reporting denials
• Ensures payor and customer satisfaction through effective communication with the Interdisciplinary Team
• Obtains payor certification for unplanned admissions, homecare and post-acute services as required
• Initiates contact with payers for continued stay; reviews utilizing clinical information; pursues additional information as needed
• Utilizes conflict resolution, critical thinking, and negotiation skills as necessary to ensure timely resolution of issues
• Identifies concurrent third-party payers denials and notifies Case Managers for immediate intervention and escalation to the Medical Director/department leadership
• Coordinates denial and appeals process and responds to all third-party payer denials
• Applies appropriate clinical criteria to complete initial reviews within 24-48 hours of patient presentation
• Facilitates tracking and payment approval processes for the outpatient parenteral antimicrobial therapy program (OPAT)
• Assists with coordination, data entry and needed follow up support to the OPAT program
• Provides post-hospitalization telephonic follow up for OPAT patients in the community for care coordination regarding care outcomes that support the OPAT program
• Facilitates tracking and payment approval processes for Eskenazi Health inpatient overlaps receiving services at IUH
• Facilitates tracking and payment approval processes for Eskenazi Health Cardiac send-out receiving services at IUH
• Reviews claims for both inpatient overlaps and cardiac send-outs and verifies dates of service; provides to Revenue Cycle for adjudication and payment
• Facilitates tracking and payment approval processes for vendor picc lines to include charge reconciliation in EPIC
• Provides oversight and maintains readmission initiatives directly related to Target Diagnosis, Bedside education, follow-ups for vendor-automated calls
• Provides assistance for complex discharge planning placement and programs, departmental projects, authorizations and accounts payable
• Facilitates referral, tracking and payment approval processes for Eskenazi Health requiring home wound-vac services provided by in-network vendors for specialty clinics and patients discharging home

• Current Indiana RN nursing license required
• Four years of clinical nursing experience required
• Two or more years of Utilization Review experience strongly preferred

• Must demonstrate knowledge of the Utilization Management managed care…