One of the jobs done by UR, at my hospital, is looking at the medical necessity including obs vs inpt, appropriateness of services and procedures ordered, length of stay as indicated by insurance criteria, and discharge planning and dispostion. It is done concurrently based on Interquel and CMS guidelines. UR also sends all clinicals and obtains authorization from insurance companies. Lots of responsibility
. This has been done by one person; a social worker who is often referred to as the case manager (not certified). This is now changing at my hospital. A case management team has been formed. It includes 3 RN's, 1 social worker and 1 coder. It is over seen by the CCO and HIM manager. The RN's
coordinate the care to improve quality and continuity at the same time insuring fiscal responsibility for the patient and hospital. This includes:
- Assessing all admissions for medical necessity
- Patient advocate
- Clinical care coordination
- Coordinate the services associated with discharge (whether home or another facility)
- Provide patient education
- Provide post-care follow-up
- Coordinate services with other health care providers
The social worker will primarily do UR:
- Verify coverage & benefits with the health insurers to ensure the provider is appropriately paid
Our social worker also handles all psychosocial issues that involves patients and families.
This is how we set up case management and UR at our facility. These are the primary responsibilites for each discipline but we work as a team and have overlapping as needed. Hope this is helpful.