ESSENTIAL JOB FUNCTIONS:
Reviews the patient Medical Records to determine if information needed for insurance companies and or hospital requirements are present.
Maintains appropriate records for the Utilization Review/Case Management Department
Maintains and updates logs as per the department requirements; files and records are organized and thorough.
Is proficient in the collection of clinical data in order to perform clinical reviews.
Is proficient in collecting data, analyzing, and reporting to different committees and administration.
Is proficient in the knowledge of behavioral and psychiatric medical terminology.
Is proficient in the knowledge of the patient medical record.
Collects data for concurrent reviews, peer reviews, and appeals and forwards to agency for review.
Collects and analyzes data.
Promotes an environment of excellent customer service and a positive patient experience.
Maintains and updates documents of all review activities.
Files are organized, detailed and thorough.
Prepares reports as per the request of OPS Leadership and Director of Compliance/Regulatory Affairs.
Develops performance improvement activities related to medical record compliance.
Concurrent Review Audits – Reviews 33% of all open medical records to ensure compliance and medical necessity each month for a 100% total open chart review each quarter.
Discharge Audits – Reviews 100% of all discharge charts to ensure 100% compliance with documentation.
Admission Audits (8-day audits) – Reviews 100% of admissions to ensure compliance and medical necessity documentation.
Transfer Audits – Reviews 100% of all charts being transferred to another location prior to the patient’s departure.
Chart Thinning – Periodically assesses and thins documents maintained in the paper chart.
End of Employment Audits – Conducts 100% of an employee’s caseload to ensure all billable services are authenticated prior to an employee’s departure from API employment.
Proficient in excel and word document.
Assists the Program Director in maintaining the program in a state of ‘constant survey readiness.
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REQUIRED KNOWLEDGE, SKILLS, AND ABILITIES:
Knowledge of and the ability to demonstrate:
Develops and maintains positive working relationships both internally and between other departments and outside agencies.
Demonstrates initiative, exercises critical thinking skills, is solution focused and is a data driven decision maker.
Demonstrates efficient time management skills.
Demonstrates teamwork, motivates others, and holds others accountable.
Exhibits sound decision-making abilities.
Ensures a safe patient environment by identifying, reporting, and taking appropriate action to identify issues within the program to ensure patient safety.
Submits expense/mileage reports by the end of the month that expenses were incurred.
Skill in:
Working on plan improvements and enhancements.
Clinical assessment to provide supportive documentation that the patient meets medical necessity.
Clinical assessment of the patient’s treatment goals.
Ability to:
Professionally handle confidential material and associated issues.
Analyze complex information and applies expert knowledge of health plans to produce high quality work, products, and service.
Take responsibility for actions, projects, and people.
Make quick, clear decisions which may include tough choices, after considering the risks.
Advocate for the patient’s need for extending their treatment authorization.
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REQUIRED EDUCATION, EXPERIENCE, AND CERTIFICATIONS:
Two (2) years of professional work experience in employee benefits administration in a multi-plan environment.
Demonstrated knowledge of employee benefits laws and regulations preferred.
A master’s degree or above in Clinical Care, Business or Public administration or related area of study with a major emphasis in employee benefits administration and/or employee training, development and education may be substituted for one (1) year of experience.
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