ğollow up on all payer authorization determinations to ensure completion prior to closure of record.Provides clinical review to health plans as required by the health plan and/or the Utilization Review plan.Ğnsures that all bedded outpatient services that require admit to hospital are screened for appropriate level of care status.Reviews daily surgery schedule for planned admissions to ensure that services are screened for appropriate level of care status.Performs admission, continued stay and discharge reviews.Ěpplies evidence based medical necessity screening criteria as defined by the Utilization Review plan. Validates patient registration status with physician order against medical necessity screening criteria.Clinical reviews and continued stay authorizations will be documented in the appropriate electronic system. The RN Utilization Management Specialist facilitates timely transmission of admission, concurrent and discharge reviews to the appropriate payer to ensure all days are authorized and documented. The RN Utilization Management Specialist confers and reviews with physicians on medical admitting information to assess medical necessity and uses evidence-based criteria to consider the anticipated length of stay, level of care, intensity of service to support access to services. The RN Utilization Management Specialist coordinates communication with admitting financial counselors, case management team, providers, patient financial services, and payers to ensure all services provided by the hospital are authorized by appropriate payer.
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