About McLaren Flint's Utilization Management Department

Utilization Management Department

Roles & functions of the Utilization Management Department: Utilization Management Reports to: CFO and VPMA Utilization Management’s Leadership Team (with photos) Paula Bluhm RN BSN – Director Iantha Broussard RN BSN – Manager Christina Dittmar RN BSN – Coordinator/Surgical Liaison Hollie Green RN – Appeals Specialist

Third Party Physician Advisors':

Case Management Consultants-CMC-Physician advisory group:

  • Concurrent & retrospective admission status reviews – inpatient or outpatient
  • Readmission reviews
  • Acting member of the Utilization Review Committee-Flint
  • Condition Code 44 review
  • Peer-to-peer discussion with third party payers on behalf of hospital physicians
  • Participates in retrospective appeals & state level hearings on behalf of McLaren Hospital

Roles within the Department:

  • Appeals Specialist: coordinates/handles the appeals process for third party payor denials, primarily RAC related activities and commercial appeals beyond the first level, requiring complex clinical review. Also, supports the overall quality, completeness of clinical documentation and intensity of service application during the appeal process to ensure proper reimbursement is achieved.
  • Surgical Coordinator: Ensures admission status of elective surgeries & procedures is compliant with CMS and third party payer guidelines. Collaborates with OR boarding and physician office staff in pre-procedure review of boarded cases to verify the planned procedure, confirm or obtain required ICD & CPT codes, and request physician documentation to support NCD or LCD requirements. Monitors UM department staff post-surgical & post-procedure reviews maintaining continuity of admission status & setting.
  • UR Nurse: Performs medical record review using hospital / payer approved criteria to determine appropriate admission in a hospital setting (inpatient vs. observation) based on medical necessity. Actively seeks additional clinical documentation from the physician to optimize hospital reimbursement when appropriate and fulfill the requirement for the physician certification statement in accordance with the 2 Midnight rule.
  • CIS Nurse (ED Review Specialist): Educates & communicates with other members of the health care team regarding compliant clinical documentation, admission status determination, and collaborates with the CM team in identifying placement/discharge planning needs for follow-up
  • Data Coordinator: Provides coordination and administrative services for the Appeals Specialist and Utilization Management Department. Abstracts data from the medical record to support the appeals process. Uploads & maintains data utilizing an internal denials tracking system for third party payer denials. Interacts with third party payers to promote process improvement initiatives, obtain authorization & monitor compliance with contractual arrangements and/or state guidelines. Tracks & trends outcomes utilizing a variety of reporting formats.
  • Administrative Assistants: Provides administrative services and support for Utilization Management and other Management staff. Completes status changes in Paragon. Selects condition codes when processing type change for all Medicare patients in order to facilitate compliant billing in accordance with CMS guidelines as directed.
  • Case Management Consultants – Physician Advisors
    • Concurrent & Retrospective appeals
    • Status Determinations
    • Conduct Peer-to-Peers
    • Condition 44 Determinations