USPI Utilization Review/Appeals RN New

Overview

Who We Are

We are a community built on care. Our caregivers and supporting staff extend compassion to those in need, helping to improve the health and well-being of those we serve, and provide comfort and healing. Your community is our community.

Our Story

We started out as a small operation in California. In May 1969, we acquired four hospitals, some additional care facilities and real estate for the future development of hospitals. Over the years, we've grown tremendously in size, scope and capability, building a home in new markets over time, and curating those homes to provide a compassionate environment for those entrusting us with their care.

We have a rich history at Tenet. There are so many stories of compassionate care; so many "firsts" in terms of medical innovation; so many examples of enhancing healthcare delivery and shaping a business that is truly centered around patients and community need. Tenet and our predecessors have enabled us to touch many different elements of healthcare and make a difference in the lives of others.

Our Impact Today

Today, we are leading health system and services platform that continues to evolve in lockstep with community need. Tenet's operations include three businesses - our hospitals and physicians, USPI and Conifer Health Solutions.

Our impact spreads far and deep with 65 hospitals and approximately 510 outpatient centers and additional sites of care. We are differentiated by our top notch medical specialists and service lines that are tailored within each community we serve. The work Conifer is doing will help provide the foundation for better health for clients across the country, through the delivery of healthcare-focused revenue cycle management and value-based care solutions.

Together as an enterprise, we work to save lives and can accept nothing less than excellence from ourselves in service of our patients and their families, every day.

Job Summary:

The USPI Utilization Review/Appeals RN is responsible to facilitate effective resource coordination to help patients achieve optimal health, access to care and appropriate utilization of resources, balanced with the patient’s resources and right to self-determination across United Surgical Partners International (USPI) Hospitals. The individual in this position has overall responsibility for ensuring that care is provided at the appropriate level of care based on medical necessity. This position manages medical necessity process for accurate and timely payment for services which may require negotiation with a payer on a case-by-case basis. This position integrates national standards for case management scope of services including:

• Utilization Management services supporting medical necessity and denial prevention
• Coordination with payers to authorize appropriate level of care and length of stay for medically necessary services required for the patient
• Compliance with state and federal regulatory requirements, TJC accreditation standards and USPI policy
• Education provided to payers, physicians, hospital/office staff and ancillary departments related to covered services and administration of benefits
• Recovering revenue associated with disputed/denied clinical claims or those eligible for clinical review
• Preparing and documenting appeal letters based on industry accepted criteria.
  
  

Responsibilities:

Responsibilities

Clinical Denials/Appeals

• Performs retrospective (post –discharge/ post-service) medical necessity reviews to determine appellate potential of clinical disputes/denials or those eligible for clinical review.
• Constructs and documents a succinct and fact-based clinical case to support appeal utilizing appropriate module of InterQual® criteria (Acute, Procedures, etc.). If clinical review does not meet IQ criteria, other pertinent clinical facts are utilized to support the appeal. Pertinent clinical facts include, but are not limited to, documentation preventing a safe transfer/discharge or documentation of medical necessary services denied for no authorization.
• Demonstrates ability to critically think, problem solve and make independent decisions supporting the clinical appellate process.
• Demonstrates proficiency in use of medical necessity criteria sets, currently InterQual®, as evidenced by Inter-rater reliability studies and other QA audits.
• Demonstrates basic patient accounting knowledge i.e. UB92/UB04 and EOB components, adjustments, credits, debits, balance due, patient liability, etc.
  
  

Utilization Management

• Balances clinical and financial requirements and resources in advocating for patient needs with judicious resource management
• Promotes prudent utilization of all resources (fiscal, human, environmental, equipment and services) by evaluating resources available to the patient and balancing cost and quality to assure optimal clinical and financial outcomes
• Completes and sends admission and concurrent reviews for payers with an authorization process identifies and documents Avoidable Days using the data to address opportunities for improvement
• Coordinates clinical care (medical necessity, appropriateness of care and resource utilization for admission, continued stay and discharge) compared to evidence-based practice, internal and external requirements.
  
  

Payer Authorization

• Assures the patient is in the appropriate status and level of care based on Medical Necessity and submits case for Secondary Physician review per USPI policy
• Ensures timely communication and documentation of clinical data to payers to support admission, level of care, length of stay and authorization
• Advocates for the patient and hospital with payers to secure appropriate payment for services rendered
• Prevents denials and disputes by communicating with payers and documenting relevant information
• Manages payer dispute processes utilizing secondary review, peer to peer and payer type changes
  
  

Education

• Ensures and provides education to physicians and the healthcare team relevant to the:
• Effective progression of care,
• Appropriate level of care, and
• Safe and timely patient transition
• Provides healthcare team education regarding resources and benefits available to the patient along with the economic impact of care options
  

Compliance

• Ensures compliance with federal, state, and local regulations and accreditation requirements impacting case management scope of services
• Adheres to department structure and staffing, policies and procedures to comply with the CMS Conditions of Participation and USPI policies
• Operates within the RN scope of practice as defined by state licensing regulations
• Remains current with USPI Case Management practices
  
  

Physical Demands

• The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• Ability to lift 15-20lbs
• Ability to travel approximately 25% of the time; either to facility sites, headquarters or other designated sites
• Ability to sit and work at a computer for a prolonged period conducting medical necessity reviews and appeal letters

Qualifications:

Requirements

Required: 5 years of acute hospital or behavioral health patient care experience with at least 2 years utilization review in an acute hospital, surgical hospital, or commercial/managed care payer setting. Must be currently licensed, certified or registered to practice profession as required by law or regulation in state of practice or policy. Active RN license for state(s) covered. Experience in writing appeals.

Preferred:

• Accredited Case Manager (ACM). Previous classroom led instruction on InterQual® products (Acute Adult, Peds, Outpatient and Procedures).
• Patient Accounting experience a plus. Managed care payor experience a plus either in Utilization Review, Case Management or Appeals.
• Interaction with facility Case Management, Physician Advisor, and Revenue Cycle Team is a requirement.
• May require travel up to 25% travel across USPI hospitals. The selected candidate will be required to pass a Motor Vehicle Records check.
  
  

Compensation

• Pay: $70,096-$112,112 annually. Compensation depends on location, qualifications, and experience.
• Management level positions may be eligible for sign-on and relocation bonuses.
  
  

Benefits

The following benefits are available, subject to employment status:

• Medical, dental, vision, disability, life, AD&D, and business travel insurance
• Paid time off (vacation & sick leave)
• Discretionary 401k match
• 10 paid holidays per year
• Health savings accounts, healthcare & dependent flexible spending accounts
• Employee Assistance program, Employee discount program
• Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, auto & home insurance.
• For Colorado employees, paid leave in accordance with Colorado’s Healthy Families and Workplaces Act is available.