Registered Nurse - Clinical Accreditation Manager - Mhsd

Title: Registered Nurse - Clinical Accreditation Manager

Performs an initial utilization review of patients for appropriateness of setting using industry standard utilization clinical criteria including, but not limited to InterQual, Milliman Care Guidelines (MCG), etc. Collaborates with the Attending of record and the Physician Advisor as indicated for review of any patient not meeting criteria for level of care ordered. Performs continued stay and extended stay reviews when there is a change to a higher level of acuity, authorized days expire, required by the insurance payer contractual agreement, stay is denied or reduced to a lower level of care.

Responsibilities:

• Educate staff, physicians, patients, and families in the case management process.
• Review new admissions and continued stay patients to determine whether MCG criteria is met.
• Engage physicians to establish the optimal DRG, length of stay and expected date of discharge.
• Interface with representatives of third party payors to assist with the certification process and the discharge planning process, responding to requests for reviews in a timely fashion to avoid denials.
• Facilitate member access to community based services
• nitiates utilization review for preauthorization and post service reviews
• Utilizes knowledge of community resources and the member's benefit structure
• Interacts with providers and facilities in a professional, respectful manner
• Recognizes quality of care issues and escalates the issues appropriately
• Assists members with the coordination of services from various settings as appropriate
• Complies with all CCSs standards for documentation