Utilization Review Manager - Home Care jobs in Iowa

Essential Duties and Responsibilities:

• Interview patient and family members to obtain information about home environment, family relationships, health history, and patients personality traits.

• Assist patients and family to understand, accept, and follow medical recommendations.

• Perform a variety of services such as arranging for discharge, placement of patients into foster or nursing homes and alleviation of anxieties and fears.

• Utilize resources to assist patient to resume life in the community or to learn to live with a disability.

• Collaborates with patients, families, medical and hospital staff in order to formulate plans of care.

• Services as a liaison between hospital and community resources.

• Assures all Medicare/Medicaid admissions meet admission criteria of specific program.

• Completes follow up on all admissions that do not meet criteria, or may be a discharge problem.

• Issues non-coverage notices to Medicare/Medicaid patients when necessary.

• Completes initial clinical review and continued stay review. Reports pertinent clinical information to approved third-party payers. Assists with meeting guidelines for managed care programs. 

• Assures that referrals are complete for reimbursement.

• Communicates with community agencies to provide medical information as needed to facilitate discharge and continuity of care.

• Works with nursing to identify, document and provide appropriate follow-up for place of care variations for all patients.

• Documents and records progress accurately on medical record.

• Conducts medical care evaluation studies as directed by Utilization Management, i.e., patient admissions, duration of patient hospitalization, ancillary and professional services, etc.

• Collaborates on development and broader implementation of critical pathways for target populations through medical record review, analysis of physician orders, discharge criteria and other data as appropriate.

• Assists with the collection and maintenance of records as needed by department, governmental oversight organizations (OSHA, DHS, etc.) and as required by law.

• Provides input for the development of the annual department budget.

• Reports denials and other problems to the attending physician and starts the initial appeal process as determined by the payer.

• Documented on reviews, outcomes, denials and the appeal process.

• Serve on committees and attend meetings as requested by supervisor.

• Assess needs for care coordination in Outpatient and Ancillary Departments.

• Complete QAPI activates for discharge planning, utilization and swing bed.

• Participates in and attends Utilization Review and Revenue Cycle meetings as directed by supervisor.