Utilization Review Specialist LPN

Retrospectively reviews discharged medical record for medical necessity criteria and sends pertinent clinical information to meet guidelines for additional length of stay to MCO via fax, Provider Link, or telephone.  Gathers and disseminates Utilization Management information to medical staff departments, Nursing departments, Care Management and Senior management as necessary.  Retrospectively reviews medical record for clinical denials. Composes a detailed summary of care and sends appeals to MCO, Medicare, or RAC for reversal of original determination.  May serve on the Medical Record/ Utilization Review Committee, providing detailed logs of denial activity and appeal results.  Maintains the Status Change Database.  Performs retrospective clinical reviews/appeals as part of denial process.

The UR Specialist will be cross trained to work for the Commercial Resource Analyst when the need arises. Act as liaison to managed care organizations. Communicates with attending physicians regarding utilization issues.  Assign patients that have had insurance verified to the UR Specialists on Provider Link.  Send corresponding initial clinical and H&P’s to commercial companies, managed Medicare, VA, and SC Medicaid. Serve on committees as assigned. Perform other duties as assigned.