Utilization Review RN​/Documentation Specialist

This position has the ability to be hybrid upon the successful completion of the orientation period and at the manager's discretion. Includes weekend and holiday rotation.

• Graduate of a professional school of nursing with licensure, or eligible for licensure as an RN in the Commonwealth of Pennsylvania.

• At least 3 years of experience with Interqual Level of Care Criteria, MCG, or available software program and knowledge of local and national coverage determinations preferred.
• Recent work experience in the hospital or insurance industry preferred (within the past 3 years).
• Familiarity with procedure status indicators and inpatient-only listings preferred.
• Must have proficient computer skills, as well as effective communication skills, both verbal and written.
• Knowledge of, but not limited to, current coding guidelines and methodologies, MSDRG, APR-DRG, HCCs; ICD-10-CM/PCS coding guidelines and conventions.

• Conducts inpatient pre‑admission and admission review for Medicare and Medicaid beneficiaries, as well as private insurance members and self‑pay patients based on CMS guidelines.
• Uses Interqual Level of Care Criteria, MCG, or available software program to screen for inpatient level of care or observation services based on physician documentation, H&P, treatment plan, potential risks, and basis for expectation of a two‑night stay.
• Understands and applies federal law regarding the use of Hospital Initiated Notice of Non‑Coverage (HINN), Medicare Outpatient Observation Notice (MOON), and Advance Beneficiary Notice (ABN) for all applicable patients.
• Ensures that commercial payers are immediately advised if their members do not qualify for acute level of care according to the criteria used.
• Keeps current on all regulatory changes that affect delivery or reimbursement of acute care services. Uses knowledge of national and local coverage determinations to appropriately advise physicians.
• Consistently identifies and records information on any progression‑of‑care/patient flow barriers.
• Consults with medical staff, care team, and case managers as necessary to resolve immediate progression‑of‑care barriers through appropriate administrative and medical channels.
• Engages care team colleagues in collaborative problem‑solving regarding appropriate utilization of resources.
• Promotes the use of best practice guidelines at point‑of‑entry and notes any deviances.
• Recognizes and responds appropriately to patient safety/risk factors.

• Actively participates in daily huddles, rounds and patient care conferences. Consults with hospitalist/nurse/physician to maintain knowledge about intensity of services and the progression of care.
• Identifies potentially wasteful or misused resources and recommends alternatives if appropriate by analyzing clinical protocols.
• Maintains appropriate documentation on each patient to include specific information of all resource utilization activities.
• Identifies and records episodes of preventable delays or avoidable delays due to failure of progression‑of‑care processes.
• Educates members of the patient’s care team on the appropriate access to and use of various levels of care.
• Represents utilization management at various committees, professional organizations, and physician groups as needed.
• Promotes use of evidence‑based protocols and/or order sets to influence high‑quality and cost‑effective care.
• Promotes medical documentation that accurately reflects findings and interventions, presence of complications or comorbidities, quality and safety indicators, and patient’s need for continuing stay.
• Confers with attending physician and APP if medically unnecessary inpatient treatment is contemplated. Issues the appropriate HINN if not resolved.

• Confirms patient’s readiness for discharge based on medical necessity for continued acute care stay.
• Consults with the patient’s nurse to confirm agreement by the patient and the care team concerning the discharge plan.
• Opens a communication channel with post‑acute services arranged through the resource center to stay current on finding and…