Lead Quality Utilization Spc

Salary depends on experience
Posted on 10/31/17
5 - 7 years experience
Misc. Healthcare
Salary depends on experience
Posted on 10/31/17

Denial Management AND Revenue Cycle, Assures appropriate, accurate and timely billing and reimbursement of outstanding account balances as it relates to the revenue cycle and denial management, including: Payor denial management and appeal;

Negotiation of payments at appropriate levels of care and reimbursement; Retrospective, pre-billing review of admission and continued stay of selected diagnosis; Holding of bills of hospital stays not meeting medical necessity criteria or level of care guidelines; Screening of billing WIP cases; Screening of pre-processor cases from Patient Financial Services (PFS); provides billing directives for PFS; Screening of weekly COW (conversion outside billing window) cases and provides billing directives for PFS; maintains COW process documentation. Drafts appeal letters in response to denials by payors, the Recovery Audit Contractors (RAC).and other auditing agencies.

Collaborates with EHR on case review, audits and the appeal process.

Reviews cases escalated by the Clinical Quality Utilization Specialists for appropriateness and accuracy of billing in accordance with medical necessity and level of care guidelines. Makes decisions regarding the appropriate billing of these cases, communicates accurate billing directions to Patient Financial Services, and maintains appropriate documentation of this process.

Mentors Clinical Quality Utilization Specialists and Payor Specialists on issues related to utilization review, payor specifications and recovery audit contractors (RAC) Reviews and evaluates Managed Care contracts for the purposes of assessing the feasibility of implementing contract terms within the Clinical Quality and Documentation Department. Recommends negotiation of individual and universal contract terms as appropriate. Reports denial trends to Managed Care and Clinical Quality and Documentation Leadership. Actively Participates in Clinical Performance Improvement Activities related to Clinical Quality and Documentation.

Assists in the collection and reporting of financial and revenue cycle indicators including rates, denial and appeals, and performance against level of care guidelines. Reports organizational, service line and department-specific trends and outcomes, as needed, to various quality improvement and operational committees including but not limited to the Utilization Management Committee. Collaborates with physician/clinician teams to educate providers on level of care and medical necessity requirements and participates in improvement efforts to advance systematic and individual practitioner outcomes.

Analyzes information gathered from denial appeal, evaluating patient accounts, and auditing of hospital records to identify opportunities for system improvements and staff education. Provides data and reports to support the outcomes of the department and assists in the analysis of data as needed. Participates in the development, implementation, evaluation and revision of quality utilization tools in collaboration with the healthcare team.

Other, Participates on departmental and hospital committees and taskforces as assigned. Complies with Northwestern Memorial Hospital policies on patient confidentiality including HIPPA requirements and Personal Rules of Conduct. Facilitates review of high risk cases by the Office of General Counsel, Risk Management, PFS, and Patient Representative department, and informs appropriate members of the healthcare team as to interventions. Coordinates interventions in collaboration with the healthcare team. AA/EOE.


· Bachelors Degree in Nursing and 5 years experience in an acute care setting.

· Mastery of utilization management and level of care guidelines.

· Proven leadership skills to affect positive Quality Utilization outcomes.

· Organizational, team building, coaching, and conflict management to influence the achievement of clinical quality and documentation outcomes.

· Analytical skills necessary to independently collect, analyze, and interpret data, resolve problems requiring innovative solutions and to negotiate in sensitive situations.

· Basic computer skills including word processing and spreadsheets.

· Registered Nurse Licensure in the State of Illinois.


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