Job Description
The UR Coordinator at BCMC reviews documentation on patient charts and confers with physicians regarding the plan of diagnosis and treatments. This is a SAFETY SENISITIVE position that reports directly to the CNO.
Position Accountabilities :
- Reviews documentation on patient charts to verify that patient meets admission criteria.
- Identifies, codes and documents reason for admissions and assigns initial length of stay for the patient, using screening criteria and length of stay guidelines.
- Places DRG sheet in front of chart of Medicare patients for physician's information on 1- DRG assigned, 2- number of days paid by Medicare, 3- Medicare discharge date, 4- complication or co-morbidity needed to increase DRG, 5- other diagnoses that would increase DRG, 6- severity of illness and intensity of service noted, and 7- AFMC discharge criteria.
- Reviews medical charts of in-patients to ascertain whether the attending physician's progress notes document the plan of diagnoses and treatment.
- Confers with the attending physician regarding diagnoses, planned discharge dates, and reasons for not discharging patient on expected date.
- Reviews patient's response to physician's treatment to justify need for continued hospitalization.
- Determines the number of additional hospitalization days required, taking into consideration patient response to treatment, additional diagnoses or complications, and treatment plan.
- Refers to physician advisor for peer review, admissions and continued stays that are questionable.
- Follows up with the physician advisor on referred cases to ensure that documentation is provided by the attending physician.
- Initiates the notification to attending physician that the patient's condition and plan of treatment do not meet the level of care and medical necessity requirements for payment by the Federal Program.
- Facilitates discharge planning for patients by identifying the need for discharge planning early in the patient's stay and discusses with discharge planning department.
- Alerts appropriate persons of potential discharge problems.
- Monitors the discharge planning activities to ensure timely discharge of patients.
- Reviews all Medicare patient charts after discharge, and reports patients that overstayed final DRG assignment days.
- Prepares monthly overstay report for medical staff meeting.
- Reviews in-patient charts with insurance, verifies insurance coverage, and is in contact with appropriate insurance companies daily to discuss clinical review for continued stay.
- Provides pre-certification numbers of insurance patients to insurance department for proper billing.
- Notifies AFMC (Medicaid) of patients overstaying four days to authorize additional days needed.
- Reviews charts and notifies Medicaid on patient pay admissions that qualify for Medicaid after discharge, to authorize Medicaid payment if additional days were used.
- Reviews observation charts daily for correct discharge time posted for doctor's information.
- Conducts monthly meeting with Utilization Review committee.
- Other duties as assigned.
Job Qualifications Education: State licensure as a Registered Nurse
Experience & Training: Knowledge and experience in Case Management
The qualified candidate chosen for this role will be a part of the Management Leadership team at BCMC. Monthly meeting attendance is required.
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