The USPI Utilization Review/Appeals RN is responsible to facilitate effective resource coordination to help patients achieve optimal health, access to care and appropriate utilization of resources, balanced with the patient’s resources and right to self-determination across United Surgical Partners International (USPI) Hospitals. The individual in this position has overall responsibility for ensuring that care is provided at the appropriate level of care based on medical necessity. This position manages medical necessity process for accurate and timely payment for services which may require negotiation with a payer on a case-by-case basis. This position integrates national standards for case management scope of services including:

• Utilization Management services supporting medical necessity and denial prevention
• Coordination with payers to authorize appropriate level of care and length of stay for medically necessary services required for the patient
• Compliance with state and federal regulatory requirements, TJC accreditation standards and USPI policy
• Education provided to payers, physicians, hospital/office staff and ancillary departments related to covered services and administration of benefits
• Recovering revenue associated with disputed/denied clinical claims or those eligible for clinical review
• Preparing and documenting appeal letters based on industry accepted criteria.

RESPONSIBILITIES
Clinical Denials/Appeals

• Performs retrospective (post –discharge/ post-service) medical necessity reviews to determine appellate potential of clinical disputes/denials or those eligible for clinical review.
• Constructs and documents a succinct and fact-based clinical case to support appeal utilizing appropriate module of InterQual® criteria (Acute, Procedures, etc.). If clinical review does not meet IQ criteria, other pertinent clinical facts are utilized to support the appeal. Pertinent clinical facts include, but are not limited to, documentation preventing a safe transfer/discharge or documentation of medical necessary services denied for no authorization.
• Demonstrates ability to critically think, problem solve and make independent decisions supporting the clinical appellate process.
• Demonstrates proficiency in use of medical necessity criteria sets, currently InterQual®, as evidenced by Inter-rater reliability studies and other QA audits.
• Demonstrates basic patient accounting knowledge i.e. UB92/UB04 and EOB components, adjustments, credits, debits, balance due, patient liability, etc.

Utilization Management

• Balances clinical and financial requirements and resources in advocating for patient needs with judicious resource management
• Promotes prudent utilization of all resources (fiscal, human, environmental, equipment and services) by evaluating resources available to the patient and balancing cost and quality to assure optimal clinical and financial outcomes
• Completes and sends admission and concurrent reviews for payers with an authorization process identifies and documents Avoidable Days using the data to address opportunities for improvement
• Coordinates clinical care (medical necessity, appropriateness of care and resource utilization for admission, continued stay and discharge) compared to evidence-based practice, internal and external requirements.

Payer Authorization

• Assures the patient is in the appropriate status and level of care based on Medical Necessity and submits case for Secondary Physician review per USPI policy
• Ensures timely communication and documentation of clinical data to payers to support admission, level of care, length of stay and authorization
• Advocates for the patient and hospital with payers to secure appropriate payment for services rendered
• Prevents denials and disputes by communicating with payers and documenting relevant information
• Manages payer dispute processes utilizing secondary review, peer to peer and payer type changes

Education

• Ensures and provides education to physicians and the healthcare team relevant to the:
  • Effective progression of care,
  • Appropriate level of care, and
  • Safe and timely patient transition
  • Provides healthcare team education regarding resources and benefits available to the patient along with the economic impact of care options

Compliance

• Ensures compliance with federal, state, and local regulations and accreditation requirements impacting case management scope of services
• Adheres to department structure and staffing, policies and procedures to comply with the CMS Conditions of Participation and USPI policies
• Operates within the RN scope of practice as defined by state licensing regulations
• Remains current with USPI Case Management practices

Physical Demands

• The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
  • Ability to lift 15-20lbs
  • Ability to travel approximately 25% of the time; either to facility sites, headquarters or other designated sites
  • Ability to sit and work at a computer for a prolonged period conducting medical necessity reviews and appeal letters

REQUIREMENTS
Required: 5 years of acute hospital or behavioral health patient care experience with at least 2 years utilization review in an acute hospital, surgical hospital, or commercial/managed care payer setting. Must be currently licensed, certified or registered to practice profession as required by law or regulation in state of practice or policy. Active RN license for state(s) covered. Experience in writing appeals.

Preferred:

• Accredited Case Manager (ACM). Previous classroom led instruction on InterQual® products (Acute Adult, Peds, Outpatient and Procedures).
• Patient Accounting experience a plus. Managed care payor experience a plus either in Utilization Review, Case Management or Appeals.
• Interaction with facility Case Management, Physician Advisor, and Revenue Cycle Team is a requirement.
• May require travel up to 25% travel across USPI hospitals. An MVR will be run on the final candidate.

Compensation

• Pay: $70,096-$112,112 annually. Compensation depends on location, qualifications, and experience.
• Management level positions may be eligible for sign-on and relocation bonuses.

Benefits

The following benefits are available, subject to employment status:

• Medical, dental, vision, disability, life, AD&D and business travel insurance
• Paid time off (vacation & sick leave)
• Discretionary 401k with up to 6% employer match
• 10 paid holidays per year
• Health savings accounts, healthcare & dependent flexible spending accounts
• Employee Assistance program, Employee discount program
• Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, auto & home insurance.
• For Colorado employees, paid leave in accordance with Colorado’s Healthy Families and Workplaces Act is available.

Tenet Healthcare/United Surgical Partners International (USPI) complies with federal, state, and/or local laws regarding mandatory vaccination of its workforce. If you are offered this position and must be vaccinated under any applicable law, you will be required to show proof of full vaccination or obtain an approval of a religious or medical exemption prior to your start date. If you receive an exemption from the vaccination requirement, you will be required to submit to regular testing in accordance with the law.

#LI-BO2