Patient Accommodations​/Utilization Review Coordinator LPN

Overview

Patient Accommodation LPN is responsible for all patient status review and related correction on discharge as needed. Under the supervision of Utilization Review Manager the LPN will review all activity sheets and physician orders to ensure all patient status requirements were met. The LPN will work closely with Patient Accommodations and Case Management. Evaluates patients for appropriateness of admission type and setting, utilizing a combination of clinical information and Inter Qual guidelines.

The Utilization Review Nurse utilizes clinical skills to support the coordination and documentation and communication of medical services and/or benefit Administration determinations. Collect information, to render appropriate medical necessity, benefit determinations. Identify patients for referral opportunity to integrate with other product services and programs. The Utilization Nurse also serves on the liaison between the Physicians, patients, payers and Case Managers regarding termination of payment, denial notification and expedited appeals.

Has access to highly sensitive, confidential information. Expected to work under minimal management supervision.

• Analyzes each of the assigned medical records for the purpose of admission and concurrent review using screening criteria. Intervenes with appropriate parties regarding inappropriate admissions, delays in discharge and the over-utilization of hospital resources.
• Monitors the utilization of observation services and collaborates with the Case Manger regarding correct status.
• Collaborates with the Case Manager to determine patient’s appropriateness for acute hospital level of care.
• Monitors patient’s clinical course to verify patients continued need for acute hospital level of care.
• Enter documentation into third-party system as required.
• Provides clinical information as necessary to obtain authorization for acute inpatient care.
• Refers cases not meeting acute inpatient criteria to a physician advisor and assists with his/her review of the case
• Works with Patient Registration/Financial Counselor(s) to identify correct insurance source and proper billing.
• Verifies patient admission information for each assigned patient within 24 hours of patient’s admission (next business day).
• Collaborates with the Case Manager to identify referrals to Financial Counselors.
• Provides third party payers with concurrent review information as needed to comply with payers requirements for documentation of medical necessity.
• Document denial billing requirements in the Billing Office system.
• Negotiates resolution disagreements over the need for acute hospital level of care with the insurer.
• Collects and documents data on each admitted patient on an ongoing basis.
• Documents all patient status and/or observations status according to policies and procedures.
• Demonstrates a working knowledge of the order entry process and transcription of physician orders.
• Identifies Potential Avoidable Days per department policy.
• Gathers information for statistical monitors, plus special projects within Case Management Department.
• Delivers denial letters from all payers to the beneficiary or proper representative; explain appeal rights.
• Maintains records in a complete, detailed and orderly manner.
• Updates and documents in the Case Management system pertinent clinical information by utilizing screening criteria and assigns next review date.
• Responsible to support and participate in department strategies and efforts focused on improving length of stay (LOS).
• Responsible to support and participate in department strategies and efforts focused on improving clinical documentation by physicians.
• Is knowledgeable of hospital mission, vision, and values and performs in a manner to support…