Director: Carol L. Wise, MS, RN, BC, CPHQ
- Concurrent review of all inpatient admissions from the quality, utilization management and risk management perspectives.
- Communication of clinical information to third party payers for certification of patient stays.
- Facilitation of medical necessity denial and appeals, both for commercial payers and Medicaid patients.
- Coordination of hospital utilization management concerns with the Vice President of Medical Affairs, the Chief Finance Offices, attending physicians, residents and other health care team members.
- Tracking and trending of identified quality, utilization and risk management concerns.
- Coordination of information for third party payer scorecards.
- Provision of data support for the clinical practice guideline teams.
- Overall support for the JCAHO and other regulatory surveys.
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