A class incumbent monitors patient charts to determine if recordkeeping is adequate for compliance with Federal and State standards and regulatory requirements.
Nature and Scope
The class incumbent reports to the Director of Planning and Quality Assurance and is responsible for the utilization review function in a large psychiatric hospital. A class incumbent monitors patient charts for timeliness, completeness and appropriateness of documentation to insure compliance with Medicare, Medicaid and licensing agency standards and third party payer regulations. Typical contacts are with medical and nursing staff concerning deficiencies in patient care documentation and with other staff regarding patients' insurance coverage and benefits. A class incumbent also interacts with external reviewers and insurance representatives concerning documentation of treatment services rendered, levels of care and verification of available insurance coverage/benefit days.
Essential functions are fundamental, core functions common to all positions in the class series and are not intended to be an exhaustive list of all job duties for any one position in the class. Since class specifications are descriptive and not restrictive, incumbents can complete job duties of similar kind not specifically listed here.
Examines patient charts to analyze the appropriateness and clinical necessity of admissions, continued stays and support services.
Conducts reviews of patient charts for completeness of documentation in support of active psychiatric care or general psychiatric care.
Prepares reports of chart deficiency findings and submits to treatment units for correction. Follows up to ensure corrections are made.
Conducts chart reviews to ensure compliance with Federal, State and licensing agency standards and third party payer regulations.
Communicates with responsible department heads, unit directors, utilization review physician advisors and the committee to ensure the identification of inappropriate allocations of hospital resources and initiates corrective actions.
Initiates denial and reinstatement letters to notify patients, family and third party payers that level of care has been changed affecting payment process.
Maintains records of charts reviewed and deficiencies identified.
Knowledge, Skills and Abilities
The intent of the listed knowledge, skills and abilities is to give a general indication of the core requirements for all positions in the class series; therefore, the KSA’s listed are not exhaustive or necessarily inclusive of the requirements of every position in the class.
Knowledge of utilization review principles, techniques and methodologies.
Knowledge of Federal, State and licensing agency standards and insurance regulations.
Knowledge of hospital-wide clinical and support services available to patients.
Knowledge of clinical requirements as related to diagnosis and treatment planning.
Knowledge of psychiatric and medical terminology.
Skill in analyzing patient care and treatment and adequacy of documentation.
Ability to establish and maintain effective working relationships with professional and paraprofessional staff and external reviews.
Ability to prepare clear reports and correspondence.
JOB REQUIREMENTS for Utilization Reviewer Applicants must have education, training and/or experience demonstrating competence in each of the following areas:
Three years experience in health or human services work such as applying theories, principles, laws and practices of health or human services programs and services that assist with and improve life for individuals, families, or communities in the areas such as financial support, employment, unemployment, housing, health care, disease prevention, substance abuse, child protective services, physical/mental health treatment and prevention, rehabilitation.
Six months experience in analyzing and evaluating professional services for direct patient care such as medical or clinical services, social services, psychology, physical therapy, occupational therapy, or nursing services.
Six months experience in interpreting laws, rules, regulations, standards, policies, and procedures.
Six months experience in using an automated information system to enter, update, modify, delete, retrieve/inquire and report on data.
Six months experience in narrative report writing.
Knowledge of alcohol, drug and mental health treatment programs.