Utilization Review

Utilization Review provides clinically-based care management to support the delivery of effective and efficient patient care. Has the overall accountability for the utilization management and discharge planning for patients within the assigned caseload. Collaborates with other members of the health care team to identify appropriate utilization of resources and to ensure reimbursement. Utilizes criteria to confirm medical necessity for admission and continued stay.

With the patient, family and health care team, creates a discharge plan appropriate to the patient’s needs and resources.

Completes an initial screen of all patients within 24 hours of admission utilizing specific criteria to identify needs related to utilization management and/or discharge planning. Refers appropriate cases to Discharge Planner based on established referral criteria and professional judgment.

Integrates the discharge planning/coordination and utilization review functions in the case management role.

Collaborates with all members of the multidisciplinary team to facilitate the care coordination processes for the assigned caseload.

Evaluates patients for appropriateness of admission type and setting, utilizing a combination of clinical information, screening criteria, and third party information.

Validates admission criteria with third party payers, including onsite and telephonic Care Managers, as well as Primary Care and Attending Physicians. Recommends alternative care sites where appropriate.

On a daily basis, identifies cases that fail to meet criteria and promptly reviews the case with the patient’s physician to resolve the issue. Refers unresolved cases to the Care Management Director by 3pm of the same day.

Collaborates with the third party payers to anticipate denial of payment and proactively addresses issues contributing to a potential denial.

Retrospectively addresses denials by reviewing the patient record and care management worksheets. Writes the letter of appeal for pertinent denials.

Conducts concurrent admission and continued stay reviews based on appropriate utilization review criteria.

Obtains continued stay certification as needed.

Assesses the presence of Severity of Illness/Intensity of Service, ISSI, criteria in the patient record.

Proactively follows and intervenes on open cases to include concurrent appeals of denials.

Provides clinical review, including clinical reviews, to payers in accordance with established standards, procedures and policies.

Proactively anticipates concurrent denials and, in collaboration with the Care Manager, intervenes to prevent the denial where possible.

Reviews and collects medical records data for quality monitoring, compliance audits, risk management, and clinical outcome reporting as directed.

Refers cases to and consults with Care Managers and Social Workers to promote appropriate continued stay or discharge.

Refers to and consults with medical staff and other internal staff as needed to facilitate accurate documentation and assure appropriate, timely discharge.

Documents authorization and days approved data as outlined in the departmental policy and procedure.

Identifies potential barriers to discharge or transfer and communicates them to the care team to spearhead resolution of the issues where possible.

Collaborates and communicates with the patient’s interdisciplinary team.

Identifies consistent issues related to reimbursement and discharge planning and communicates them to the department leadership.

Assesses the patient/family for care needs during hospitalization to establish an effective discharge plan in collaboration with…