The Utilization Management Department enacts the hospital UR Plan. The department provides for the assessment of the medical necessity of admission and continued stay, appropriate bed status, denials management, and outlier review. The department provides clinical information to third party payers to assure medical necessity requirements are met to secure authorization.
Utilization Management Nurse Role:
Utilization Management Nurses work within the multidisciplinary team to determine medical necessity of admission and continued stay in the hospital as well as correct patient classification and efficient use of resources. They conduct robust utilization review. Utilization Management Nurses use established criteria to determine appropriateness of admission and continued stay and work with payers to assure ongoing authorization for continued stay. They contribute to meeting OHSU’s strategic plan of safe LOS reduction and reduction in readmission rates.
Specifically, the UM Nurse does the following:
- Reviews pre-admissions for correct classification and admission order.
- Performs Utilization Review for each patient on their assigned daily census using established medical necessity guidelines.
- Communicates with payers regarding authorization and medical necessity, utilizing excellent negotiating skills.
- Reviews order/classification discrepancies and take actions to resolve the discrepancy.
- Discusses cases with providers and Case Managers as needed, including attending physicians and escalation to the Care Management Physician Advisor when indicated.
- Assesses for and tracks potentially avoidable hospital days.
- Assesses for and records reasons for readmissions.
- Participates in and supports strategic initiatives to reduce readmissions and LOS.
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- Attends and contributes to Outlier Review rounds on ad hoc basis.
- Provides education regarding Utilization Management issues to the Multidisciplinary team.
- Prepares and conducts presentations, as assigned, to their assigned physician groups regarding issues related to Utilization Management in conjunction with the Care Management Physician Advisor.
- Educates providers regarding documentation requirements that support medical necessity determinations.
- Prepares and presents reports as requested by UM Management.
- Facilitates MD Advisor to payer discussions.
- Assesses whether there is a basis for written appeal for cases in which payment is denied due to medical necessity concerns. Seek input from attending physicians and physician advisor as needed.
- Composes persuasive and grammatically correct written appeals for claims denied by payers for lack of medical necessity whether denied pre or post payment. This may include denials through retrospective audits by payers or through government audits.
- Presents Case Studies illustrating systems issues that adversely affect LOS and/or readmission rates to the Clinical Resource Management Committee and the Care Management Department.
- Serves as member of department and/or hospital committees and task forces working on issues related to Utilization Management, as assigned.
- Delivers Condition Code 44 notices, Observation notices(MOON), and Medicare Important Messages(IMM) in the absence of sufficient clerical support.
- Educates patients about their classification and financial implications as needed.
- Communicates in writing with attending physicians about UR Committee cases.
- Facilitates Utilization Review case reviews in accordance with Medicare Conditions of Participation: Utilization Review.
- Coordinates and processes Medicare discharge appeals along with clerical support.
- Conducts secondary reviews for peers, assessing appropriate classification and medical necessity.
- Communicates closely with the multidisciplinary team about patients’ expected hospital course, expected discharge date, GMLOS, and authorization status.
- Communicates status upgrades and downgrades with the Bed Flow Manager.
- Documents according to departmental policy.
- Works with coding, patient business services, surgery schedulers, registration, and c integrity department to determine correct billing and coding status for complex cases and assure correct classification.
- Provides feedback to managed care contracting regarding insurance company billing policies and practices that adversely affect OHSU’s ability to collect proper reimbursement for care provided.
- Leads the effort to assure compliance with CMS and other insurance regulations related to Utilization Review.
- Maintains current knowledge of, and complies with regulatory requirements of DNV, Medicaid, Medicare, CMS, applicable state regulations and Oregon Nurse Practice Act.
- Other UM activities as assigned
Department Specific Working Conditions:
Utilization Management follows patients on every inpatient, observation, and overnight day stay unit and the Emergency department. Some work occurs in support of procedural areas as well.
Each Utilization Management Nurse has access to a computer work station as this is a teleworking position. There is heavy frequent use of computers and telephones.