- Apply utilization criteria to review admissions, associated levels of care, and continued stays.
- Communicate with third-party payers for initial and concurrent clinical reviews.
- Review patient charts to determine whether patients continue to meet medical necessity.
- Document actions and information shared with care team members or third-party payers.
- Discuss cases with the clinical care team and management when patients no longer meet inpatient medical necessity criteria.
- Refer cases to management when they exceed expected length of stay or cost, or involve over- or underutilization of resources.
- Perform verbal or fax clinical reviews with payers as appropriate.
- Collect data on length-of-stay variances, lost days, costs, discharge or transition barriers, and denied days.
- Prepare appeals for denied cases when appropriate.
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