Job Description

Location: Steward Health Care
Posted Date: 6/10/2021

To serve as a liaison with providers, case managers, hospital leadership and payers on utilization management and revenue integrity. Provide education to ensure physician documentation appropriately supports the actual care provided.

KEY RESPONSIBILITIES:

  • Assist CM/UR staff with level of care determination appropriateness and length of stay management
  • Assist UR staff with oversight, regulatory updates and guidance
  • Peer to Peer discussions and provider support
    • Mentor providers with P2P strategies and summaries with high yield overturn elements specific to the denial received
    • Back up resource for P2P completion in the case of an absent or unavailable provider
  • Denials
    • Communicate with payers to facilitate approvals and prevent denials
    • Review and approve all Medicare Part B self-denials
    • Evaluate commercial payer denials for appropriateness and compliance concerns
    • Elaborating appeal letters and payer complaints
    • Support for AAC though education, appeal templates and industry standard evidence based guidance
    • Feedback to providers on documentation improvement opportunities
  • Education, Mentoring and Facilitation: Physicians, Residents, Midlevel Providers, Appeals Nurses, Case Managers, CDI, Coding, Quality
    • Educate individual hospital staff about ICD coding guidelines (e.g., co-morbid conditions, outpatient vs. inpatient) and clinical terminology to improve their understanding of severity, acuity, risk of mortality, and DRG assignments on their individual patient records
    • Educate individual hospital staff about appropriate utilization, medical necessity documentation, payer specific guidelines, regulatory matters as they relate to UR and compliance
    • Present at department of medicine, hospitalist & surgery meetings
  • Assisting with UR process for complex cases and long stay observation reviews
    • Order clarifications
    • Appropriate level of care
    • Medical necessity documentation
    • Observation management
  • Joint operating committee discussions with medical directors
    • Challenge payers on non-compliant and inappropriate denial practices when trends are identified
  • UM committee feedback on denials and performance opportunities
    • Discuss denial trends, prevention and process improvement opportunities
  • Medicare ALJ hearings
    • Prepare case defense taking into account the applicable federal regulations, national and local coverage determinations
  • Medicaid / State Fair Hearings
    • Prepare case defense taking into account the applicable state regulations and UR benchmarks
  • Contracting
    • Advise on UR related hospital contract stipulations and requirements as they relate to commercial contracts and guidelines
  • Collaborate with leadership on workflows and process improvement opportunities to increase performance and quality

EDUCATION/EXPERIENCE/LICENSURE/TECHNICAL/OTHER:

  • Education: Doctorate
  • Experience: One year of utilization management, case management or peer review documentation experience in hospitals or health plans. In clinical practice within the past five years.

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The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal ability to furnish information. 41 CFR 630-1.35.

Application Instructions

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