The Utilization Reviewer/ Inpatient Payor Specialist is responsible for working behind the scenes to maximize the quality and cost of efficiency of health services and coordinates pre-certifications, re-certifications, the denial management and appeals process and initial and concurrent reviews. Through regular reviews and audits, they ensure that the patients receive care needed without burdening the health care system with unnecessary procedures, ineffective treatments or lengthy hospital stays.. Essential Functions and Responsibilities Communicates secondary review decisions determining appropriate patient status provided by secondary reviewer process. Communicate with payers to obtain approvals for the appropriate care level Serve as a resource on payor requirements for severity of service determinations for outpatient and acute inpatient admissions. Provide timely payor feedback to Case Managers and Social Workers; notify the Case Manager when additional clinical information may be required to ensure that services will be approved at the acute level of care as required by the payor; maintain communication with the inpatient case management team to ensure timely progression through the plan of care. Responsible for ensuring pre-certification/authorizations for post-acute services, initial, concurrent reviews, authorizations not obtained by Patient Registration/ Admitting or the Doctor's office and clinics for direct admissions and procedures. Document and maintains pre-certification/authorization information accessible by the healthcare system. Ensure the provision of quality patient care, effective utilization of available health services, review of medical necessity of admissions, and necessity for continued stay in hospital; analyzing patient records to ensure compliance with insurance company reimbursement policies and accrediting standards. Demonstrate clinical astuteness with the assigned patient population and is responsible for managing each patient's plan of care, monitoring for appropriate resource utilization, and collaborating with the inpatient team as well as outpatient providers to coordinate the patient's transition plan of care. Provide primary nurse support through all aspects of utilization management Assess degree of medical necessity for any patient seen in the Emergency Department and perform Utilization Review using the Eskenazi Health approved clinical decision support criteria. Review patient admission for appropriateness and type; refer case to Medical Director/department leadership for review/course of action when case fails to meet admission standards. Facilitate the most accurate/appropriate patient status for care Communicate payor issues/concerns regarding the initial level of care, continued stay, denials and discharge plans to the Medical Director/department leadership Support the denial management process and participate in tracking/ reporting denials. Ensure payor and customer satisfaction through effective communication with the Interdisciplinary Team Obtain payor certification for unplanned admissions, homecare and post-acute services as required Contact payers for initial and continued stay reviews utilizing clinical information and pursues additional information as needed Function as a resource with admitting staff to coordinate patient insurance and payment information Strategize to reduce the length of stay and resource consumption within the appropriate length of stay. Identify concurrent third-party payers denials; notify Case Managers for immediate intervention and escalation to the Medical Director Collaborate with Emergency Physicians and Attending Physicians to ensure that patients meet criteria for Admission or Placement on Observation Status Oversight of the initial admission review, utilizing criteria, within 24-48 hours of the patient's admission to the hospital to ensure appropriateness of the assigned level of care and timely implementation of the treatment plan. Apply appropriate clinical criteria to complete initial reviews within 24-48 hours of patient presentation. Job Requirements Current Indiana nursing license Minimum of 4 years clinical nursing experience required. Knowledge, Skills & Abilities Must demonstrate knowledge of the Utilization Management managed care processes. Ability to work weekends and holidays required. Ability to demonstrate knowledge of levels of care of Inpatient and Outpatient status. Competency in the following areas required: interpersonal, written/verbal communication, and negotiation skills diplomacy, flexibility, and professionalism cohesive networking with the Interdisciplinary Team