RN CONTINUED STAY REVIEW SPECIALIST

General Purpose of Job:

The Continued Stay Review Specialist performs utilization review using accepted screening criteria for medical necessity. This review includes appropriateness of health care services, utilization of hospital resources, and quality of patient care rendered at Sparrow Hospital. The role combines clinical, business and regulatory knowledge and skill to reduce significant financial risk and exposure caused by concurrent and retrospective denial of payment for services provided.

Essential Duties:

This job description is intended to cover the minimum essential duties assigned on a regular basis. Associates may be asked to perform additional duties as assigned by their leader. Leadership has the right to alter or modify the duties of the position.

• Assesses medical documentation for medical necessity using an established screening tool to determine the appropriate level of care for neonate, pediatric, adolescent, adult and geriatric patients.
• Responsible to provide key clinical information to obtain authorizations from payers as needed.
• Integrates knowledge of regulatory, business, and insurance requirements into determinations concerning admissions and length of stay.
• Communicates with providers about medical screening results, and payer issues regarding patient classification.
• Assists with the education of medical staff and other health care professionals regarding utilization of resources and regulations that impact the delivery of care, payer requirements, and patient classifications.
• Coordinates an insurance physician peer to peer call when applicable.
• Collaborates with physician advisors as necessary and identifies issues for escalation.
• Learns and applies payer specific requirements and rules regarding utilization review.
• Collaborates with the health care team regarding length of stay, treatment, and patient classification implications.
• Verifies and documents the outcome of the utilization review, payer response, and physician interactions in the electronic record.
• Demonstrates the ability to deliver and educate messaging letters to patients and patient representatives.
• The above duties and responsibilities are intended to describe the general nature and level of the work being performed by caregivers assigned to this job. The are not an exhaustive list of all duties and responsibilities associated with it.