- Apply utilization criteria to assess admissions, levels of care, and continued stays.
- Conduct initial and concurrent clinical reviews with third-party payers.
- Review patient charts to confirm continued medical necessity.
- Document actions and information shared with care team members and payers.
- Alert clinical teams and management when a patient no longer meets inpatient medical necessity criteria.
- Refer cases exceeding expected length of stay or cost, or involving resource over- or underutilization, to management.
- Conduct verbal or fax clinical reviews as appropriate.
- Collect data on length-of-stay variances, lost days, costs, discharge barriers, and denied days.
- Prepare appeals for denied cases when appropriate.
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