TRA Utilization Review California Ju Ca

TRA Utilization Review California Ju Ca

The individual in this position 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. 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 Tenet policy; Education provided to payers, physicians, hospital/office staff, and ancillary departments related to covered services and administration of benefits.

Responsibilities

The individual?s responsibilities include the following activities:a) accurate medical necessity screening and submission for Physician Advisor review,b) securing and documenting authorization for services from payers,c) managing concurrent disputes,d) collaborating with payers, physicians, office staff, and ancillary departments,e) timely, complete, and concise documentation in the Tenet Case Management documentation system,f) maintenance of accurate patient demographic and insurance information,g) identification and documentation of potentially avoidable days,h) identification and reporting over and underutilization,i) and other duties as assigned.Utilization Management: Completes and sends admission and concurrent reviews with clinicals for patients whose payers have an authorization process. 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. 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 Tenet 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. May oversee work delegated to Utilization Review LVN/LPN and/or Authorization Coordinator.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 Tenet policies. Operates within the RN scope of practice as defined by state licensing regulations. Remains current with Tenet Case Management practices.

Qualifications

Education:

Required: Graduate of an accredited school of nursingPreferred: Academic degree in nursing (bachelor's or master's degree)

Experience:

Required: 2 years of acute hospital or behavioral health patient care experience with at least 1 year utilization review in an acute hospital or commercial/managed care payer setting

Certifications:

Required: Registered Nurse (RN). 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.Preferred: Accredited Case Manager (ACM).

Physical Demands:

Lift/position up to 25 lbs. Push/pull up to 25 lbs of force. Frequent sitting. Moderate standing, walking, reaching, stooping, and bending. Manual dexterity, mobility, touch, auditory to perform all the related duties of the position

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