156

156.1

T.H. Utilization Review/Quality Assurance

In many hospitals the Quality Assurance and Utilization Review function are combined. Administrators state that this makes for increased efficiency versus a split function whereby each record is examined by two separate individuals. Incumbents in these positions ensure that patient care services are appropriately recorded and utilized in accordance with hospital standards of quality and the policies of regulatory agencies. Review of the position with hospital administrators indicates possible changes will be mandated by regulatory agencies which could result functional changes.

T.H. Utilization Review/Quality Assurance Senior Coordinator: (SL—4)

Awareness of external review requirements that affect the utilization program and hospital in general. Supervises the day-to-day activities of the department, responsible for the Utilization Review assignment. Conducts reviews of pre-admission certification forms; conduct admission and continued stay reviews; assign lengths of stay by diagnosis following HFCA, IPRO and University Hospital criteria; review all patients’ Utilization Review data forms on admission to determine discharge planning needs; refers to the Social Work Department, all high risk patients or any patient requiring discharge planning assistance; reviews all cases which are hospitalized 20 days or more and refers them the Social Work Department if discharge planning assistance is needed; follow—up of all cases referred to Social Work Department to assure timely University Hospital intervention and documentation of discharge planning; initiates and updates forms cyclically for patients awaiting skilled nursing facility, may submit to Long Term Case Coordinator in the Social Work Department; contacts appropriate home care agency to arrange for Visiting Nurse, equipment and etc. for patients waiting for discharge planning assistance that is lesser than skill level; conducts retrospective reviews of all patients discharged from University Hospital; maintains availability in assigned areas for contacting attending physicians, house staff and other hospital personnel to ensure ongoing documentation of the care being provided, the treatment plan and discharge plan, or the correction for any other deficiencies identified; assures that University Hospital physicians comply with the submission of various forms related to Utilization Review, (i.e. Discharge Planning, Quality Assurance and DRG Programs); assists in functions requiring special skills such as data collection, abstracting medical record data from medical charts, or engaging in special studies and/or projects; refer to Utilization Review Physician Advisors, patients that do not meet University Hospital IPRO or other external agency requirements; ensures that all Medical Management Analysis, and Quality Assurance screening is performed within 24 hours of admission and every three days through discharge; immediately refers all patients to Quality Assurance Coordinator when diverse patient occurrences are identified; attends monthly Utilization Review/Quality Assurance Department meetings, as assigned or necessary; manages continuing education program.

Preferred Qualifications:

RN required, BSN and four (4) years clinical experience and one (1) year Utilization Review/Quality Assurance experience.

 

State Title Code: 3744528

SUNY Title Code: 3875

Revised: 10/1/87

156.2

.

T.H. Utilization Review/Quality Assurance Coordinator: (SL-3)

Conducts reviews of pre—admission certification forms; conducts admission and continued stay reviews of all patients admitted to the hospital within one working day of admission and every three to four days during continued hospital stay; assigns lengths of stay and determines levels of care other than acute by diagnosis following HCFA, IPRO and University Hospital criteria; reviews all patients’ Utilization Review data forms on admission to determine discharge planning needs; refers to the Social Work Department, all high risk patients or any patient requiring discharge planning assistance; reviews all cases which are hospitalized 20 days or more and refers them to Social Work Department if discharge planning assistance is needed: follows up of all cases referred to Social Work Department to assure timely University Hospital intervention and documentation of discharge planning; initiates and updates forms cyclically for patients awaiting to Long Term Case Coordinator in the Social Work Department; contacts appropriate home care agency to arrange for Visiting Nurse, equipment and etc for patients waiting for discharge planning assistance that is lesser than skill level; conducts retrospective reviews of all patients discharged from University Hospital; maintains availability in assigned areas for contacting attending physicians, house staff and other hospital personnel to ensure ongoing documentation of the care being provided, the treatment plan and discharge plan, or the correction for any other deficiencies identified.

Preferred Qualifications:

RN required with two (2) years clinical experience.

 

State Title Code: 3744527

SUNY Title Code: 3878

Revised: 10/1/87


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