Coordinates and completes the clinical reviews for all patient medical records while working closely with CMO (Chief Medical Officer). Actively participates in the Case management and UR meetings. Serves as on-going educator to all departments. Responsible for reviewing patient charts in order to assess whether the clinical criteria for admission and continuation of treatment is being met; gathering data and responding to request for records from payers/fiscal intermediary etc.; gathering clinical and fiscal information and communicating status of both open and closed accounts for multiple levels of Utilization Review and Case Management reporting. Able to work independently and use sound judgment. Knowledge of Federal, State, and intermediary guidelines related to inpatient, acute care hospitalization, as well as lower levels of care for the continuity of treatment. Coordinates discharge referrals as requested by clinical staff, fiscal intermediary, patients, and families. Performs other duties as assigned.
Education and Work Experience
1. Master of Public Health (MPH) or post-graduation in a related health care field is required.
2. Medical Graduate, Dental Graduate required.
3. Knowledge of Clinical Pathophysiology and Pharmacology required.
1. ECFMG Certification And/or Bachelors or higher from a US-based accredited institution in a Health and Human Services field is highly preferred.
2. Utilization Review/Case Management experience is highly preferred.
3. 1+ year of clinical experience in acute care setting preferred.
4. Excellent written and verbal communication skills. Excellent critical thinking skills.
5. Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff, coding staff and hospital management staff.
6. Ability to work independently in a time-oriented environment.
7. Computer data entry with 10-key preferred, with accurate typing speed of 35 wpm preferred.
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