General Summary:

Reviews and assesses appropriateness of patient admission/continued stay.  Works with Financial Case Management Representatives to monitor use of insurance benefits to maximize service to patients.  Provides timely, pertinent insurance benefits information to clinical staff so that they will provide care within patients’ benefits package and thereby optimize third party payment for services.  Assists physicians in preparing appeals when payment has been denied by insurance companies.  Assists in the implementation of the Hospital Utilization Review Plan.  Provides consultation and/or education to clinical staff regarding monitoring studies and medical records reviews.  Represents hospital in involuntary hearings process.  Serves as a member of various clinical committees and provides staff support to committee chairpersons.

Knowledge, Skills, and Abilities Required:

Work requires comprehensive knowledge of a broad range of medical diagnoses, treatment modalities, therapeutic services and intervention techniques, and knowledge of utilization review practices and procedures - acquired through completion of a Bachelor’s degree from an accredited institution in nursing, allied health, records administration, or closely related field. Work requires comprehensive knowledge of patient medical records, health insurance provisions, psychiatric diagnoses, and utilization review practices - acquired through two to three years of related experience.