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Qual Resource Screener
JOB SUMMARY
Reviews clinical records to monitor admission and continued stays in accordance with established policies and procedures, regulatory and accrediting bodies, using national criteria and/or criteria developed by third party payors. In collaboration with the health care team, identifies and secures services necessary to meet the continuing health care needs of patients. Collects, analyzes, and reports clinical information to measure and improve effectiveness, appropriateness and efficiency of patient care.
Key Job Responsibilities
Essential Function
Using established criteria, reviews medical records of all inpatient and observation patients on the day of admission or the first working day following admission, to determine medical necessity and appropriateness of admission or observation status. Notifies third party payors of admissions when required.
- Reviews patient census daily to identify new admissions and provide initial reviews for insurance providers(s).
- Performs concurrent and discharge reviews on all inpatients and provides to insurance provider(s) as required.
- Determines if severity of illness and intensity of service are documented to validate appropriateness of the plan of care and ensure compliance with joint commission, state and other agency requirements.
Certifies the admission and/or continued stay when documentation in the medical record is appropriate and the case is determined to be medically necessary, in accordance with established criteria. Documents rationale for case determinations and determines next review date. Refers all cases to Case Management‘s Medical Director when medical necessity and/or appropriateness of care is questioned, in accordance with established criteria and third party payor requirements.
- Obtains authorization number for new admissions within twenty-four business hours and documents number of days approved, next review date and level of care in the utilization review screen.
- Verifies and documents Medicare/Medicaid days as required.
- Verifies and documents insurance coverage for TN Care, Medicaid/ Medicare as well as self pay patients.
- Obtains applicable contact information (i.e. name, number) from providers as required for follow-up.
- Forwards insurance denials to case manager and possible need for physician to physician appeal. Follows process until final option is utilized to appeal denial. Maintains documentation of all action taken involving a denial.
- Identifies and documents avoidable days, notifies Director and completes a variance report
Screens physician documentation for timeliness, appropriateness and completeness as it pertains to the utilization management process. Provides education and follow-up as necessary to enhance patient care or improve department outcomes and operations.
Provides data for research and administrative support for department operations, special projects and studies.
Essential Function
- Collects and records clinical data to identify trends in quality/resource management and to measure, evaluate and improve the effectiveness, appropriateness and efficiency of patient care.
- Provides statistical analysis of data.
- Follows-up as needed.
- Provides documentation and utilizes computer to enter and retrieve medical/patient information
- generate statistics, computations, tables or charts. Provides clear, concise, timely written documentation and updates information and computer data as required. Maintains confidentially of all information in accordance with hospital, HIPAA, compliance and other regulatory requirements.
Confers with and works collaboratively with medical/hospital staff, external claim and medical review personnel in a customer responsive and courteous manner, in compliance with MEDCARE Standards and promoting patient/customer satisfaction to coordinate and implement activities; to obtain information; answers inquiries and resolve problems regarding quality, appropriateness and/or efficiency of patient care.
Prepares and maintains required reports, records, discharge patient worksheets and files for operational, administrative and compliance purposes. Utilizes computer and information systems to enter format and retrieve data, generate statistics, computations, tables, charts and graphs.
Completes required continuous training and education, including department specific requirements to maintain current knowledge of department and hospital policies, procedures and billing practices, compliance plans, federal and state regulations, insurance requirements and accrediting standards concerning the utilization management. Responds to problems/opportunities to improve care. Supports and is involved in the organization’s Performance Improvement initiatives.
Physical Demands
A thorough completion of this section is needed for compliance with legal standards such as the Americans with Disabilities Act. The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.
Physical Demand
N/A
Rarely
Occasionally
Frequently
Constantly
Weight
Standing
X
Walking
X
Sitting
X
Lifting
X
Carrying
X
Pushing
X
Pulling
X
Climbing
X
Balancing
X
Stooping
X
Kneeling
X
Crouching
X
Crawling
X
Reaching
X
Handling
X
Grasping
X
Feeling
X
Talking
X
Hearing
X
Repetitive Motions
X
Eye/Hand/Foot Coordination
X
Education
Education Level
Education Details
Required/ Preferred
Bachelor's Degree
or equivalent experience in nursing, health information management, healthcare administration, operations management or a related field based on area of assignment.
Required
and
Education, training or experience to work with the adolescent, adult and/or geriatric patient population as assignment dictates.
Required
Work Experience
Experience
Experience Details
Required/ Preferred
Minimum 1 year experience
Twelve (12) months healthcare experience with a comprehensive knowledge of the utilization review and evaluation of quality assessment.
Required
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