SUMMARY:

Under general direction of department site manager or department director, functions as liaison for utilization review with third-party payers. Participates in the coordination of the utilization review process and activities with utilization management staff. All activities are carried out in consideration of aging processes, stages of human development and cultural and ethic considerations.
Brown University Health employees are expected to successfully role model the organization's values of Compassion, Accountability, Respect, and Excellence as these values guide our everyday actions with patients, customers and one another.

In addition to our values, all employees are expected to demonstrate the core Success Factors which tell us how we work together and how we get things done. The core Success Factors include:

Instill Trust and Value Differences
Patient and Community Focus and Collaborate

RESPONSIBILITIES:

Monitors and ensures compliance with third-party requirements related to utilization review. Serves as the liaison with third-party payers regarding patient status, and other issues related to these agreements.
Serves as consultant to other hospital departments and medical staff on utilization review issues and concerns, for example, pre-certification for admission or status for surgical patients.
Participates in the coordination of the utilization review program Serves as a resource and educator to the utilization care managers on utilization review process and InterQual criteria. Provides input to director on goals, objectives, policies, and standards as they relate to utilization review program. Coordinates and monitors the Medicare Hospital Issued Notices of Non coverage(HINNs).

Responsible for data reporting of HINNs to the utilization review committee. Responsible for denial mitigation by negotiating patient status with payors utilizing the department algorithm.
Prepares, reviews, and maintains various manual and computerized documentation, records, reports and statistics on the utilization management and denials data. Ensures completeness and accuracy. Responsible for the hospitals concurrent appeals initiative by coordinating third party appeals with the medical director of appeals ensuring timeliness and completeness of the concurrent appeal. Provides clear and concise communication and documentation to leadership and members of the denials management team regarding status of concurrent appeals.
Participates on various hospital, state and department committees to provide input for development of policies and procedures related to utilization review.
Conducts retrospective reviews and audits of hospital records to determine if level of care is appropriate and sufficiently documented. Collaborates with the department physician reviewers and physician advisors as needed to determine appropriate patient status. Collects and synthesizes quality data related to UR activity for review with manager. Provides data to patient registration, business office staff and finance as needed to make changes to patient status to ensure appropriate billing and reimbursement.

Participates in ongoing, independent study, education-related professional activities and affiliations to maintain knowledge of utilization review, discharge planning government regulations and reimbursement issues.
Participates in or leads various committees, task forces and quality improvement teams as needed. Provides case review examples to enhance learning of utilization management staff at staff meetings and as requested by utilization management leadership.

MINIMUM QUALIFICATIONS:
Licensure as Registered Nurse in the State of Rhode Island by the Rhode Island Board of Nursing or licensure as a Registered Nurse in accordance with the N

urse Licensure Compact agreement of the National Council of State Boards of Nursing.

BASIC KNOWLEDGE:
Registered nurse with license to practice in the State of Rhode Island; Bachelor’s Degree in nursing or related health science required. Working knowledge of level of care criteria is required. Knowledge of state and federal regulations is desirable.

EXPERIENCE:
Three years or more of relevant recent clinical and/or administrative experience in an acute care setting; two years of which must be directly related to utilization review activities, demonstrating organizational skills and ability to make sound clinical judgement.

INDEPENDENT ACTION:
Performs independently within the department’s policies and procedures. Refers specific complex problems to utilization management leadership when clarification of the departmental policies and procedures are required.

SUPERVISORY RESPONSIBILITY:
None.

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EEO Statement:

Brown University Health is committed to providing equal employment opportunities and maintaining a work environment free from all forms of unlawful discrimination and harassment.

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Driving Required: