Description: Responsible for providing concurrent and retrospective clinical patient record reviews applying utilization, quality, and risk management screens. Provides concurrent clinical updates for private review companies and Medicaid to obtain certification of care. knowledgeable in commercial insurance requirements and Milliman Guidelines and Interqual review products to determine appropriate admission, level of care, and discharge criteria. Interacts with medical staff, hospital employees and physician office staff to obtain information needed and to educate where appropriate. Serves as QIO and managed care contact and/or resource person; Coordinates utilization review functions and communicates these to appropriate persons/departments. Responsible for developing corrective action plans for QIO correspondence. Responds to QIO quality inquires for the hospital and medical staff, keeping abreast of the regulatory changes. Responsible for coordinating appeals for inpatient and outpatient denials, regardless of payer source. Monitor appropriateness of clinical services and communicate with payer. Preceptor to new employees. Assists in the development of orientation.
Requirement: RN Graduate of an accredited school of Nursing with current Arkansas RN license. BSN or related field preferred. Minimum 3-5 years clinical experience. Minimum 1 year experience in quality/utilization review management. Working knowledge of the utilization management process required, including DRG's and other reimbursement systems and basic knowledge of QIO guidelines/regulations.