Plan, organize, and direct all aspects of the process for effective, systematic, concurrent review for both inpatients and observation/OPS patients using established indicators/criteria. Facilitates improvement in the overall quality and completeness of the medical record documentation of coders and other healthcare providers. This includes a dedicated approach to concurrent record review in order to obtain documentation that accurately describes the patient’s severity of illness and risk of mortality.  Utilizes clinical information in profiling and reporting outcomes.  Work with the CBO on denials, appeals, and variances in billing and insurance authorizations.  On an ongoing basis, educate all members of the patient care team on documentation guidelines.

Education: 

Registered Nurse (B.S. required)

Experience: 

Five years recent healthcare experience in utilization review/case management or performance improvement.  Supervisory experience required. Knowledge of the legal aspects of coding, Medicare DRG assignments, Utilization review, resource management, case management, and discharge planning is highly desired.  Experience with application of InterQual criteria is desired

Additional Skills/Abilities:

Excellent organizational, analytical, and writing skills; Ability to demonstrate critical thinking, problem-solving, and excellent interpersonal skills; Excellent time management; Ability to establish effective and appropriate communication with physicians and coding professionals; Knowledge of regulatory guidelines; Knowledge of Medicare Part A and Part B (preferred); Established ability to work with computer applications, including but not limited to Windows, Outlook, Excel, and Microsoft Word is preferred; Ability to stand and walk for long periods of time.