Posted in Other 30+ days ago.
Type: Full Time
This position supports the utilization management (UM) program by developing and/or maintaining effective and efficient processes for determining the appropriate admission status based on the regulatory and reimbursement requirements of various commercial and government payers. The Senior Clinical Admission Review Specialist effectively and efficiently manages a diverse workload in a fast-paced, rapidly-changing regulatory environment and collaborates with treating physician to ensure the patient is placed in the most appropriate status based on the clinical indications documented in the medical record.
Essential Job Duties
* Work closely with local case management and payers and have an understanding of denial management and appeals process
* Performs independent, criteria based, documentation assessment, via medical record review and discussion with the physician as needed, on all patients referred
* Applies clinical criteria and guidelines to advise on appropriateness of admission based on the use of relevant evidence based clinical decision support tools and Medicare regulations and guidelines as appropriate
* Accurately correlates clinical based data to hospital approved criteria set
* Applies best practice and standards in the Utilization Review Entry (URE) application of Midas, and as needed within the electronic medical record that supports the appropriate level of care
* Collaborates with the physician when documentation presented does not meet evidenced based medical necessity guidelines to substantiate the patient s level of care status selection
* Works directly with the physician advisor to obtain recommendations on cases that require additional information to ensure level of care assigned is clinically appropriate
* Documents interactions and outcomes with physician advisors in the appropriate area in Midas
* Acts as a resource to the Emergency Department physicians for any issues related to appropriate status assignment of patients
* Maintains up to date knowledge regarding changes within the evidence based clinical decision support tool
* Participates in Quality Reviews and Inter Rater Reliability processes and achieves performance results at or above thresholds established by management
Case Management experience, and/or Utilization Review, Utilization Management skills in a clinical setting required
RN, required, with nursing experience in related clinical setting; Denial Management and appeals experience preferred.
* Computer proficient with strong typing skills in Microsoft applications specifically Microsoft Word and Excel
* Working knowledge of current evidence based clinical decision support tools with the ability to apply the criteria consistently and accurately (Interqual experience preferred)
* Ability to accept ownership and accountability for compliance with CMS and UHS best practice guidelines
* Ability to prioritize, problem solve and multi-task
* Proficiency in utilizing clinical software programs and electronic medical records
* Proficient understanding of patient care cost and reimbursement information
* Excellent phone and communication skills and ability to convey key concepts succinctly and clearly
* Shift: 8:30 A.M. - 5:00 P.M. Ability to work every 3rd weekend is required
This opportunity provides a rewarding career, challenging and rewarding work environment as well as growth and development opportunities within UHS and its subsidiaries, including competitive compensation, excellent Medical, Dental, Vision and Prescription Drug Plan, and 401k with company match.
One of the nation s largest and most respected hospital management companies, Universal Health Services, Inc. (NYSE: UHS) has built an impressive record of achievement and performance. Growing steadily since its inception into an esteemed Fortune 500 corporation, UHS today has annual revenue exceeding $10.7 billion. In 2019, UHS was again recognized as one of the World s Most Admired Companies by Fortune; in 2018, ranked #268 on the Fortune 500; and in 2017, listed #275 in Forbes inaugural ranking of America s Top 500 Public Companies.
Our operating philosophy is as effective today as it was 40 years ago, enabling us to provide compassionate care to our patients and their loved ones: Build or acquire high quality hospitals in rapidly growing markets, invest in the people and equipment needed to allow each facility to thrive, and become the leading healthcare provider in each community we serve.
Headquartered in King of Prussia, PA, UHS has more than 87,000 employees and through its subsidiaries operates 350 inpatient acute care hospitals and behavioral health facilities and 30 outpatient and other facilities located in 37 states, Washington, D.C., Puerto Rico and the United Kingdom. For additional information on the Company, visit our web site: http://www.uhsinc.com.
UHS is a registered trademark of UHS of Delaware, Inc., the management company for Universal Health Services, Inc. and a wholly-owned subsidiary of Universal Health Services, Inc. Universal Health Services, Inc. is a holding company and operates through its subsidiaries including its management company, UHS of Delaware, Inc. All healthcare and management operations are conducted by subsidiaries of Universal Health Services, Inc. To the extent any reference to "UHS or UHS facilities" on this website including any statements, articles or other publications contained herein relates to our healthcare or management operations it is referring to Universal Health Services' subsidiaries including UHS of Delaware. Further, the terms "we," "us," "our" or "the company" in such context similarly refer to the operations of Universal Health Services' subsidiaries including UHS of Delaware. Any employment referenced in this website is not with Universal Health Services, Inc. but solely with one of its subsidiaries including but not limited to UHS of Delaware, Inc.
UHS is not accepting unsolicited assistance from search firms for this employment opportunity. Please, no phone calls or emails. All resumes submitted by search firms to any employee at UHS via-email, the Internet or in any form and/or method without a valid written search agreement in place for this position will be deemed the sole property of UHS. No fee will be paid in the event the candidate is hired by UHS as a result of the referral or through other means.
All employment at UHS is with one of the subsidiaries of Universal Health Services, Inc., including its management company, UHS of Delaware, Inc. Universal Health Services is a holding company.
UHS is an Equal Opportunity Employer and as such, openly supports and fully commits to recruitment, selection, placement, promotion and compensation of all individuals without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status or any other characteristic protected by federal, state or local laws.