Utilization Review Analyst - Utilization Management - Full Time

The UM Analyst analyzes patient records daily to determine the appropriateness of admission, level of care, continued stay and discharge. Abstracts variances to standard pathway process. Provides ongoing support and expertise through comprehensive assessment, planning, implementation and overall evaluation of individual patient needs. Exercises concurrent review techniques utilizing evidence based guidelines such as InterQual and Milliman to communicate with multidisciplinary personnel and insurance providers; Enhances the quality of patient management and satisfaction while promoting continuity of care and cost effectiveness through integration of utilization management, case management and discharge planning. Performs various duties assigned by department management according to policies and procedures and the mission of Woman's Hospital.

Requirements:

• Graduate of an accredited school of nursing; currently licensed to practice professional nursing in the State of Louisiana.
• BSN strongly preferred.
• Must have a minimum of two years prior experience in a clinical setting, preferably Antepartum, Obstetrical, Post Partal, NICU and/or Med-Surg.
• Previous work experience in Utilization Review/Case Management with emphasis on concurrent review process is also preferred.

Responsibilities:

• Performs admission screening within 24 hours of admit for inpatient and outpatient based on criteria and standards approved by the medical staff in accordance with applicable accreditation, regulatory, and third party payor requirements.
• Reviews Medicare and CHAMPUS admissions within 24 hours of admit for medical necessity and appropriateness of admission.
• Provides data to managed care companies on patients for initial and continued stay necessity within 24 hours of receipt of call.
• Appeals denials as necessary providing supporting documentation to managed care companies. Sets up physician to physician appeals as necessary. Notifies managed care department of denials and status of appeal.
• Reviews Medicare and CHAMPUS patients for medical necessity for continued stay review utilizing generic and/or body system discharge screening criteria. Notifies Social Services for discharge planning. Provides CHAMPUS with clinical data for continued stay.
• Performs periodic medical record review using review table for elements of medical record standards. Submits these reviews to the Medical Review Analyst by the designated date.

Schedule:

Full-Time

8 hour Shift - Days

Would participate in weekend coverage rotation (Approximately every 8 weeks)

Pay Range:

Hourly Position

$30.49 - $48.00

Weekend Differential: $8.50/hour

A Work Experience with Purpose

Woman’s is one of the largest specialty hospitals for women and infants in the United States. We are recognized throughout the country for our innovative programs, and we pride ourselves in surpassing the expectations of those we serve. Providing exceptional patient care and creating exceptional patient experiences are at the center of what we do at Woman’s. Our team consistently exceeds state and national benchmarks for patient satisfaction.

Our employees, organizational culture, mission, vision, values, and benefits make Woman’s a best place to work. In fact, for the 16th year in a row, Woman’s has been recognized as a Best Place to Work by Modern Healthcare – making us the only healthcare organization to earn the distinction every year since the program’s inception. We are proud of the level of care our staff provides to our patients and each other.

If you have any questions or would like to connect with one of our recruiters directly, please e-mail josie.graham@womans.org

We are an equal opportunity employer and value diversity and inclusion at Woman’s Hospital. We do not discriminate on the basis of race, color, religion, sex, sexual orientation, age, disability, genetic information, veteran status, national origin, gender identity and/or expression, marital status or any other characteristic protected by federal, state or local law.