Utilization review focuses on health care providers reviewing patient records in order assessing if complete and accurate treatment/services occurred. UR safeguards \"against unnecessary and inappropriate medical care.\"
Utilization review also uses physician documentation and other medical records to determine a patient's discharge disposition.
Independent Review Organizations (IROs) are typically brought into utilization review instances to help ensure objective and unbiased reviews are completed.
Utilization Review Is To:
*Validate the necessity of medical services/treatment requested
*Validate if the duration of healthcare services/treatment requested occurred within the right time frame
*Validate quality and level of services/treatment provided were appropriate given the circumstances (click here for our Medical Necessity Criteria White Paper)
The primary function of the Utilization Review Nurse is to create an executive report by effectively reviewing and analyzing medical records. The executive report will include a summary, appropriate criteria/guidelines, and rationale.
Essential Job Functions:
*Comprehension of medical/surgical modalities and imaging techniques
*Analysis of clinical documentation in relation to medico-legal review
*Collect data and analyze information to make decisions regarding certification or denial of treatment. Wok must be completely documented.
*Audit and analyze patient records to ensure quality patient care and appropriateness of services
*Utilize pre-approved criteria and guidelines to validate medical necessity/appropriateness of treatment (e.g. ODG, MTUS, Milliman Care Guidelines, Interqual)
*Interpret and apply appropriate guidelines to medico-legal reviews
*Use logic and reasoning to determine and utilize appropriate evidence based guidelines
*Perform a low to moderate amount of research on a case by case basis
*Create a high-quality, professional report free of grammar or spelling errors
*Dictate all report information
*Interview or correspond with physicians to correct errors or omissions and to investigate questionable claims
*Analyze information gathered by investigation and report findings and recommendations
*Responsible for amending reports when necessary with any additional clinical information provided
*Participates in an interdisciplinary health care team to achieve positive
*Reach and maintain a 25-30 average daily case load once released from training
*Maintain a monthly Quality Assurance score of 99% or higher
*Requires regular and consistent attendance
*Other duties as assigned
Knowledge and Abilities Requirements:
*Knowledge of Basic Anatomy
*Ability to use Microsoft products; Word, Excel, PowerPoint, Outlook
*Basic office equipment experience preferred (copier, fax, shipping and receiving tools)
*Written and verbal communication skills with a demonstrated ability to deliver excellent customer service
*Communicate professionally with physicians and clients
*Ability to multi-task and quickly adapt in a fast paced environment
*Maintain a positive attitude and outstanding customer service while working closely internaly with Nexus staff, panel physicians and clients.
*Strong organizational skills
*Attention to detail
*General Typing Skills at 45wpm
*Proficiency in English with an aptitude for spelling and grammar
*Exemplary planning and time management skills
*Ability to work in high pressure, deadline driven environment
*Ability to multitask and prioritize daily workload
*High level verbal and written communications skills
*Discretion and confidentiality
*Demonstrated ability to problem solve complex, multifaceted, situations
*Ability to engage easily in abstract thought
*Strong organizational and task prioritization skills
We know that a company's success starts with its employees. We also know that an individual's success starts with the right career opportunity. As a Best of Staffing Client and Talent leader, Aerotek's people-focused approach yields competitive advantage for our clients and rewarding careers for our contract employees. Since 1983, Aerotek has grown to become a leader in recruiting and staffing services. With more than 250 non-franchised offices, Aerotek's 8,000 internal employees serve more than 300,000 contract employees and 18,000 clients every year. Aerotek is an Allegis Group company, the global leader in talent solutions. Learn more at Aerotek.com.