Senior Medical Utilization Review Analyst

Analyzes the medical records, labs, imaging, and medication records. Abstracts pertinent clinical information from these records to determine the appropriateness and the medical necessity for admission and continued stay and enters the information in EPIC within 24 hours or first business day following the admission.

Roles and Responsibilities 

• Responsible for data entry into EPIC that conforms with departmental guidelines, which include specific timeframes, and data that correlates to the patient’s illness.
• Facilitates the delivery of care and services on the patient care units by:
  • Participating in ICP rounds
  • Identifying Medicare Beneficiaries to the Interdisciplinary team during ICP rounds
  • Assisting other disciplines in order to develop a plan
  • Ensuring the accuracy of the clinical and the payer’s information obtained by the Social Worker in order to adequately plan for the patient’s discharge
  • Updating the Social Worker on the patient’s clinical status and level of care for timely discharge planning activities
  • Evaluating the appropriateness of the discharge plan in terms of feasibility, necessary funding, durability, resource, and cost efficiency
  • Coordinating the services with the HMOs and obtaining authorization for required services 
  • Providing coverage and certification information to the other disciplines as needed
  • Determining the current level of care based on established guidelines
  • Facilitating communication and access to care and services
• Takes effective, appropriate, and immediate action for all deviations that do not meet criteria or lack justification
• Assists the Physicians to document the intensity and the severity of illness. Based on documentation, recommends and assigns appropriate level of care. The Reviewer is responsible for obtaining the order for appropriate level of care from the Physician when there is no justification for the current setting.
• Completes and assign Accommodation codes for patients on ALOC in EPIC.
• Evaluates the planned interventions as they relate to the needs of the patients, monitors the patient’s progress toward the set goals, and makes appropriate documentation.
• Provides timely concurrent clinical reviews to the third-party payers (upon request), obtains certification status from the plan, and reviews daily End of Day Report provided by the HMOs and enters the payer’s decision into EPIC.
• Monitors cases that need certification from the MCOs. Informs patient accounts of cases not identified as MCO enrollees on admission in order to avoid administrative denials.
• Maintains adequate documentation in EPICs to support review activities to the MCOs as per departmental policy and procedure.
• Informs the department of all adverse determinations received for adequate follow up by sending an email to Supervisor and Appeal team.
• Notifies the managed care companies of patients requiring transfer to another facility for services not performed at Woodhull in order to obtain Authorization for transfer.
• Conducts focused reviews as assigned. Collects data, prepares, and submits timely and accurate reports as assigned.
• Assures completeness of medical record and timely submission to IPRO or Livanta LLC for the discharge appeal process.
• Serves as a resource/consultant to clinical departments regarding UR/CM issues or policies.
• Notifies the Physician Advisor of cases that do not meet criteria and document referral (Psych/Peds/OBS/Surg) responses from the Physician Advisor in EPIC.
• Maintains competency through attending seminars related to job topics (i.e. Infection Control, HIPPA, Health Care, Discharge Planning, third party regulations, etc.)
• Must be able to identify problem, collect supportive data, establish facts, define problem, draw conclusions, apply problem-solving techniques, and prepare reports as required.
• Completes other duties as assigned by the Sr. Associate Director or designee.

Minimum Qualifications

• An Associate Degree in Science which includes courses in Biology, Chemistry, Anatomy or related subjects and three (3) years experience in a hospital clinical setting in a capacity which provides thorough understanding of medical diagnosis, symptoms and treatment concepts, one year of which has been served in Utilization Review/Quality Assurance; or,
• Certification as an Accredited Records Technician, and three (3) years of experience in a capacity which provides thorough understanding of medical diagnosis, symptoms and treatment concepts, and terminology, one year of which must have been served in Utilization Review/Quality Assurance; and,
• Ability to understand and extrapolate medical information from records and through discussion with medical and nursing staff; and,
• Knowledge of third-party reimbursement systems.