BASIC PURPOSE OF THE JOB

Under general supervision and according to established procedures, performs pre-certification and extended stay reviews for patients at East Tennessee Children’s Hospital. Responsible for assuring all inpatient and observation admissions are pre-certified within the required time frames.

REPORTS TO

• Director-Health Information Management

JOB REQUIREMENTS

Supervisory Responsibilities: Yes

Minimum Education: Associates Degree Required. Bachelors preferred

Degree: Degree in Nursing or Health information Administration

License/Certification Required: RN and/or RHIA required.

Minimum Work Experience: 2 or more years Utilization Review.

REQUIRED KNOWLEDGE, SKILLS, AND ABILITIES

• Knowledge of medical terminology, anatomy & physiology, and pediatric nursing experience.
• Excellent communication skills.
• Detail-oriented with organizational and time management skills.
• Proficient in computers, word processing and computer applications.
• Problem solving skills.
• Proficient in the use of reference materials and resources.

DUTIES AND RESPONSIBILITIES

• Obtains initial pre-certification review for all admissions admitted through the emergency room. Notifies insurance companies of patient admission. Reviews and submit patient clinical to insurance companies per their policy.
• Verifies and/or obtains pre-certification for all admissions admitted directly from physician office. Performs extend stay reviews for all patients. Obtains other pre-certification reviews for procedures that are required by insurance.
• Communicates information pertaining to patient account with other relevant departments. Enters the pre-certification number and the number of days approved into Meditech; Enters the extended days that are approved accurately; Updates Meditech with the date for the next clinical update.
• Maintains paper and electronic utilization review records.
• Effectively utilizes Meditech, Trace Products, and insurance websites to obtain precertification. Participates in discharge planning.
• Processes appeals efficiently and accurately: Processes concurrent appeals on denied accounts when the patient is still in the hospital, Processes retrospective appeals on denied accounts that have been discharged, and Processes second level retrospective appeals on denied appeals when appropriate.
• Processes retrospective eligibility on accounts that have been assigned insurance and actively participates on the Utilization Management Committee.
• Provides necessary and effective training for new utilization management coordinators including training on telephones, Meditech, Trace products, and insurance websites. Maintains program compliance with all applicable laws and regulations.
• Assists outside reviewers in a courteous manner.
• Demonstrates respect and regard for the dignity of all patients, families, visitors, and fellow employees to ensure a professional, responsible, and courteous environment. Interacts with all of the above in a considerate, helpful, and courteous manner, as observed by manager and peers; Maintains confidentiality of all hospital and patient information at all times, as observed by peers and management; Continuously displays a positive attitude within the department and across departmental lines to contribute to the overall customer service program in place at hospital.
• Provides notification and clinical information to insurance companies in a courteous and professional manner.
• Consults, interacts with and assists physicians, physician advisors, practitioners, both internal and external, in a courteous and professional manner.
• Continuously displays a positive attitude within the department and across departmental lines to contribute to the overall customer service program in place at hospital.
• Assists intradepartmental and other hospital co-workers as needed in a courteous and professional manner.
• Communicates with insurance representatives in a courteous and professional manner.
• Willingly accepts any other assignment that may be requested.
• Obtains and maintains the precertification for all inpatient, observation and same day surgery patients as required by policy.
• Utilizes hospital resources and time respectfully and accountably.

PHYSICAL REQUIREMENTS

• Note: Reasonable accommodations may be made for individuals with disabilities to perform the essential functions of this position.
• Heavy lifting, pushing, and pulling is required up to 50 lbs occasionally, 20-30 lbs frequently, and 10lbs constantly to move objects of up to 150 lbs. Sudden emergency situations have the potential for exposure to lifting or moving of up to 150 lbs. Frequent bending, walking, sitting squatting, reaching, and standing are required. Keyboard/computer use and/or repetitive motions may be required.

Come work where you can make a difference every day.