Utilization Review Clinician

The client is looking at hiring a Virtual Utilization Review professional for their team at Guadalajara, Mexico.Education : Doctorate in Medicine.RESPONSIBILITIES:Provide health care services regarding admissions, case management, discharge planning and utilization review.Review admissions and service requests within assigned unit for prospective, concurrent, and retrospective medical necessity and/or compliance with reimbursement policy criteria.Assist with issues related to coding, medical records/documentation, precertification, reimbursement and claim denials/appeals. Notifies attending physician and other members of the health care team of inappropriate admissions, denials, end of authorized days, or other factors that have a reimbursement impact.Consults with attending physician when documentation in the medical record does not support admission or continued stay and seeks to ensure completeness of all clinical documentation.Functions as liaison between the Physician Advisor and the attending physician.Documents denial information in electronic medical record system including attempts at resolution/overturning of the denial.Provides all payor communication to be scanned into the system for use in appeals.Conveys and receives information efficiently to and from third party payors, physicians, patients/families, physician practices, other members of the health care team, and other external agencies.Consults with medical and treatment staff regarding client diagnosis, medical justification, length of treatment, and case documentation. Participates in utilization and peer review meetings and projects.

Creado: Jue, 01 de Ene de 1970