The primary purpose of Utilization Review/Management (UR) is to ensure that all admissions and continued stays are appropriate, based on the hospital’s admission and discharge rules and the individual’s need for inpatient treatment. These reviews are performed utilizing the patients’ medical record on admission and periodically thereafter, based on the guidelines of the hospital’s UR Plan and developed criteria sets. This plan and criteria sets were developed by the Medical Staff Quality Improvement/Utilization Review Committee and approved by the hospital’s Executive Committee and its Governing Body. When performing the reviews, the developed criteria are applied to authorize the patients’ admission and/or continued stay. If the patient’s symptoms/condition do not meet the criteria for their admission and/or continued stay in their location/unit, the case is referred for a physician advisor to review and follow up with the appropriate person(s). All reviews are performed by registered nurses who are educated in the utilization review process and application of criteria sets. Other job responsibilities of the department includes providing clinical information to review organizations for Medicaid and Medicare, third party payors and other appropriate organizations, for those clients that have coverage. The clinical information provided is obtained from the medical record of the individual patient(s) with coverage. Also, the department is responsible for providing clinical information to Local Management Entities/Area Programs to obtain authorization for the admissions and continued stays for all patients. This process and authorizations are based on the Divisions’ Bed Day Allocation Plan. These processes are to ensure the hospital will receive reimbursement for the patients’ hospitalizations. Notice: The UR Staff does not provide any patient information until appropriate consent is obtained from the patient/legal guardian. The UR Department is located in the Royster Building and is under the direction of the UR Nurse Supervisor who reports to the Chief of Standards Management. The staff includes three licensed registered nurses (2 UR Nurses and 1 UR Nurse Supervisor) and one Utilization Management Processing Assistant. For more information contact the Utilization Review Department at (919) 731-3342. |
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Cherry Hospital - Department of Health & Human Services - Division of MH/DD/SAS Updated 11/20/2007 |
