Job Description: Coordinates and completes the clinical reviews for all patient medical records while working closely with CMO (Chief Medical Officer). Actively participates in the Case management and UR meetings.
Serves as on-going educator to all departments. Responsible for reviewing patient charts in order to assess whether the criteria for admission and continuation of treatment is being met; gathering data and responding to request for records from payers/fiscal intermediary etc.; gathering clinical and fiscal information and communicating status of both open and closed accounts for multiple levels of Utilization Review and Case Management reporting. Works with health information management staff, coding staff, physicians, financial services, onsite and remote utilization review teams with regards to admission criteria, medical necessity, payment denials, and documentation issues.
Able to work independently and use sound judgment. Knowledge of Federal, State, and intermediary guidelines related to inpatient, acute care hospitalization, as well as lower levels of care for the continuity of treatment. Coordinates discharge referrals as requested by clinical staff, fiscal intermediary, patients, and families. Performs other duties as assigned.
Prime Healthcare Systems