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Wellforce Utilization Review and Denials Specialist in Lowell, Massachusetts

This position reports to the Director of Utilization Management. Responsible for review and assessment of all Commercial Payers and government payers for level of care. The Utilization Review and Denial Specialist is responsible for by applying actionable evidence based criteria and or Medical Necessity Criteria and the 2 midnight rule. If there is a conflict in the determination will work with the health care team and physician advisor. Submissions of clinical information to a third party payer must be timely as to avoid late notification. Submission is based on hospital policy.

Hours: 4 0 hours a week: weekend and holiday rotation

Job Duties & Responsibilities:

  • Is current with federal regulations, Conditions of Participation, insurance contracts and all financial clinical information.

  • Utilizes INTERQUAL and MCG to determine level of care of all patients and communicates with physician advisor if there is a discrepancy

  • Is proficient in the use INTERQUAL and MCG

  • Reviews medical records in accordance with procedure and adopted medical criteria to determine acuteness of patient’s condition.

  • Provides reviews that do not meet inpatient level of care to a physician advisor. Knows and follows rules for condition code 44

  • Ensures that patients are in appropriate admission status according to medical necessity.

  • Performs ongoing reviews each business day and reassess the appropriateness.

  • Obtains commercial census on a daily basis. Submits clinical reviews to insurers as per contract.

  • Maintains communication and collaboration among payers and healthcare team.

  • Takes initiative in solving problems with appropriate utilization.

  • Communicates with care managers and Utilization Manager and Director to resolve any conflicts.

  • Provides education and consultation on resource use and utilization review.

  • Collaborates on leadership activities that support optimal Utilization Review

  • Performs additional reviews and audits as requested to meet hospital’s reimbursement requirements.

  • Tracks all upfront denial prevention cases and reports to the Utilization Management Manager and team (prospective, retrospective and concurrent)

  • Tracks any acceptance of lower level care after medical review with the third party payer.

  • Acts as liaison with Medical staff, other departments,

  • Collaborates with Clinical Documentation Specialists to ensure reimbursement optimization through complete and essential documentation.

  • Provides information and follows through on insurance issues that could affect the case managers determination for continuum of care

  • Understands and incorporates accepted standards of care into practice areas.

  • Informs and advises hospital personnel on discrepancy in level of care determination as appropriate.

    REQUIRED QUALIFICATIONS:

  • RN with a BSN, PA, Physical Therapist, non-practicing foreign MD, certified hospital coder

  • 3-5 years in an acute care hospital setting

  • Knowledge of the disease management process

  • Proficient software computer skills

  • Possess planning, organizing, conflict resolution, negotiation and interpersonal skills

  • Independent problem identification / resolution and decision making skills

  • Ability to interact with individuals and multidisciplinary team

  • Ability to demonstrate excellent customer service with patients, providers, and health plans

    This position reports to the Director of Utilization Management.

    What We Offer:

  • Competitive salaries & benefits

  • 403(b) retirement plan with hospital match

  • Opportunities for growth

  • Tuition reimbursement

  • Free on-campus parking

    About Lowell General Hospital: Lowell General Hospital is an independent, not-for-profit community hospital serving the Greater Lowell area and surrounding communities. With two primary campuses located in Lowell, Massachusetts, we are the second largest community hospital in Massachusetts. We have the latest state-of-the-art technology and a full range of medical and surgical services for patients, from newborns to seniors. We are also a proud member of Circle Health and in collaboration with the medical community it is our promise to provide our patients with Complete connected care SM Circle Health is an Equal Opportunity Emplo yer.

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