PRN - Utilization Review Clerk
Jackson, TN
Part Time
Mid Level
Please review the job description below and let me know if you see any changes need to be made for the Utilization Review Clerk
JOB SUMMARY: The Utilization Review Clerk is responsible for obtaining initial and ongoing insurance certification of medical necessity for patients and residents during their length of stay. The position objectives are to meet admission, continued stay, and discharge needs of the resident within the reimbursement constraints, and to promote quality care.
Essential Duties & Responsibilities: To perform this job successfully, a staff person must be able to perform each of these essential duties satisfactorily. The requirements listed below represents the knowledge, skill, and/ or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties listed below:
1. Makes decisions and recommendations based on facility criteria regarding all resident admissions, continued stays, and discharges.
2. Makes certification decisions and takes positive action.
3. Assesses and interprets data relative to the residents.
4. Ensures that insurance verification, approval, and pre-certification (CON process) has taken place on all residents within specified time frames.
5. Continued stay reviews by telephone, fax, and computer as requested by third party payors/ review agencies, reporting all information necessary to obtain certification in a manner consistent with HIPAA.
6. Reviews medical records as necessary prior to release to fiscal intermediary.
7. Follows procedures for appeal of denied days and retrospective reviews in order to maximize reimbursement.
8. Promptly notifies Chief of Nursing, Director of Clinical Services, and Physician(s) of all de-certifications and private-pay residents.
9. Identifies problems and deficiencies and initiates or recommends solutions for each process.
10. Participates in data collection for open and closed medical record review.
11. Makes decisions affecting the various functions of the position, utilizing problem-solving methods.
12. Effectively utilizes all resources available in order to meet the requirements of the position.
13. Demonstrates knowledge of when to arrive at independent conclusions and when to refer a problem to others.
14. Monitors documentation for over/under utilization of special precautions and medical procedures on residents.
15. Acts as a resource to physicians and staff regarding documentation and UR issues.
16. Assists physicians in writing appeal letters, as necessary.
17. Attends Treatment Team meetings to participate in resident treatment and discharge planning, and to provide benefit information.
18. Maintains UR files, keeping past two years of records, and shredding outdated files.
19. Maintains office equipment in working condition.
20. Maintains current knowledge of medical and psychiatric care and treatment modalities in order to perform ongoing utilization review.
21. Perform and accept phone calls from various insurance providers and health plans regarding determination of request for Prior Approvals, expedited reviews and appeals.
22. Must maintain an accurate log of all communication and attempts to insurance providers and health plans.
23. Must assist the Utilization Review Coordinator and Case managers with updates on approvals and denials of requested days.
24. Must be able to work flexible hours, including overtime, evening, and weekend hours, as directed by workload and by the supervisor.
25. Helps unit staff with patient care during periods of heavy workload, or during Fire Drills or other unit disruptions as necessary.
26. Demonstrates knowledge of HIPAA, including resident rights/privacy and confidentiality (e-mail, faxes, sharing codes).
27. Maintains awareness of the safety of residents, visitors, and co-workers.
QUALIFICATIONS:
1. AGE
· At least twenty-one (21) years of age.
2. EDUCATION and/or EXPERIENCE
· Degree in nursing or human services field with appropriate, current license to practice in the State of Tennessee.
· Education acquired through on-the-job experience, reading, and seminars related to reimbursement methods, performance improvement, and Utilization Review
· Minimum of three (3) years in an acute psychiatric or residential treatment setting,
3. CERTIFICATES, LICENSES, REGISTRATIONS
· Current license in field related to degree, to practice professionally in the State of Arkansas.
4. LANGUAGE SKILLS
· Ability to read and interpret documents such as medical records, and abstract clinical details.
· Possess the ability to give attention to detail.
· Must be able to hear and speak distinctly on the telephone, or to groups of employees of the organization.
· Must have the ability to write routine reports and correspondence.
5. MATHEMATICAL SKILLS
· Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals.
6. REASONING ABILITY
· Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
7. PHYSICAL DEMANDS
· While performing the duties of this job, the employee is regularly required to stand; walk; sit; use hands to finger, handle, or feel; reach with hands and arms; climb or balance; stoop, kneel, crouch, or crawl; and talk or hear. The employee must occasionally lift and/or move a minimum of 50 pounds. Specific vision abilities required by this job include close, distant, and peripheral vision, color and depth perception, and ability to adjust focus. The employee
may occasionally be required to physically restrain residents, using authorized restraint procedures as a last resort for protection of resident and staff.
8. WORK ENVIRONMENT
· The work environment for this position is a psychiatric acute and residential facility setting. While performing the duties of this job, the employee will be exposed to residents who may ask inappropriate personal questions, display socially unacceptable personal behaviors, use profanity and sexually explicit phrases, make insulting remarks or threats regarding appearance, age, sex, or race, and exhibit defiance, dishonesty, and assaultive or self-destructive behaviors. The employee is occasionally exposed to outside weather conditions and may be subject to occasional local travel as required by facility needs. The noise level in the work environment is usually quiet to moderate.
Note: This job description is not intended to be all-inclusive; an employee will also perform reasonably related responsibilities as assigned. This organization reserves the right to review or change job duties as need arises. This job description does not constitute a written or implied contract of employment
JOB SUMMARY: The Utilization Review Clerk is responsible for obtaining initial and ongoing insurance certification of medical necessity for patients and residents during their length of stay. The position objectives are to meet admission, continued stay, and discharge needs of the resident within the reimbursement constraints, and to promote quality care.
Essential Duties & Responsibilities: To perform this job successfully, a staff person must be able to perform each of these essential duties satisfactorily. The requirements listed below represents the knowledge, skill, and/ or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties listed below:
1. Makes decisions and recommendations based on facility criteria regarding all resident admissions, continued stays, and discharges.
2. Makes certification decisions and takes positive action.
3. Assesses and interprets data relative to the residents.
4. Ensures that insurance verification, approval, and pre-certification (CON process) has taken place on all residents within specified time frames.
5. Continued stay reviews by telephone, fax, and computer as requested by third party payors/ review agencies, reporting all information necessary to obtain certification in a manner consistent with HIPAA.
6. Reviews medical records as necessary prior to release to fiscal intermediary.
7. Follows procedures for appeal of denied days and retrospective reviews in order to maximize reimbursement.
8. Promptly notifies Chief of Nursing, Director of Clinical Services, and Physician(s) of all de-certifications and private-pay residents.
9. Identifies problems and deficiencies and initiates or recommends solutions for each process.
10. Participates in data collection for open and closed medical record review.
11. Makes decisions affecting the various functions of the position, utilizing problem-solving methods.
12. Effectively utilizes all resources available in order to meet the requirements of the position.
13. Demonstrates knowledge of when to arrive at independent conclusions and when to refer a problem to others.
14. Monitors documentation for over/under utilization of special precautions and medical procedures on residents.
15. Acts as a resource to physicians and staff regarding documentation and UR issues.
16. Assists physicians in writing appeal letters, as necessary.
17. Attends Treatment Team meetings to participate in resident treatment and discharge planning, and to provide benefit information.
18. Maintains UR files, keeping past two years of records, and shredding outdated files.
19. Maintains office equipment in working condition.
20. Maintains current knowledge of medical and psychiatric care and treatment modalities in order to perform ongoing utilization review.
21. Perform and accept phone calls from various insurance providers and health plans regarding determination of request for Prior Approvals, expedited reviews and appeals.
22. Must maintain an accurate log of all communication and attempts to insurance providers and health plans.
23. Must assist the Utilization Review Coordinator and Case managers with updates on approvals and denials of requested days.
24. Must be able to work flexible hours, including overtime, evening, and weekend hours, as directed by workload and by the supervisor.
25. Helps unit staff with patient care during periods of heavy workload, or during Fire Drills or other unit disruptions as necessary.
26. Demonstrates knowledge of HIPAA, including resident rights/privacy and confidentiality (e-mail, faxes, sharing codes).
27. Maintains awareness of the safety of residents, visitors, and co-workers.
QUALIFICATIONS:
1. AGE
· At least twenty-one (21) years of age.
2. EDUCATION and/or EXPERIENCE
· Degree in nursing or human services field with appropriate, current license to practice in the State of Tennessee.
· Education acquired through on-the-job experience, reading, and seminars related to reimbursement methods, performance improvement, and Utilization Review
· Minimum of three (3) years in an acute psychiatric or residential treatment setting,
3. CERTIFICATES, LICENSES, REGISTRATIONS
· Current license in field related to degree, to practice professionally in the State of Arkansas.
4. LANGUAGE SKILLS
· Ability to read and interpret documents such as medical records, and abstract clinical details.
· Possess the ability to give attention to detail.
· Must be able to hear and speak distinctly on the telephone, or to groups of employees of the organization.
· Must have the ability to write routine reports and correspondence.
5. MATHEMATICAL SKILLS
· Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals.
6. REASONING ABILITY
· Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
7. PHYSICAL DEMANDS
· While performing the duties of this job, the employee is regularly required to stand; walk; sit; use hands to finger, handle, or feel; reach with hands and arms; climb or balance; stoop, kneel, crouch, or crawl; and talk or hear. The employee must occasionally lift and/or move a minimum of 50 pounds. Specific vision abilities required by this job include close, distant, and peripheral vision, color and depth perception, and ability to adjust focus. The employee
may occasionally be required to physically restrain residents, using authorized restraint procedures as a last resort for protection of resident and staff.
8. WORK ENVIRONMENT
· The work environment for this position is a psychiatric acute and residential facility setting. While performing the duties of this job, the employee will be exposed to residents who may ask inappropriate personal questions, display socially unacceptable personal behaviors, use profanity and sexually explicit phrases, make insulting remarks or threats regarding appearance, age, sex, or race, and exhibit defiance, dishonesty, and assaultive or self-destructive behaviors. The employee is occasionally exposed to outside weather conditions and may be subject to occasional local travel as required by facility needs. The noise level in the work environment is usually quiet to moderate.
Note: This job description is not intended to be all-inclusive; an employee will also perform reasonably related responsibilities as assigned. This organization reserves the right to review or change job duties as need arises. This job description does not constitute a written or implied contract of employment
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