EdiPhy Advisors: Case Management &First Line Utilization Review Support

EdiPhy Advisors RNs are available to support hospital and other

health care provider case management staff with first line medical

necessity screening. Often, hospitals leverage our availability and

expertise to fill gaps in on-site case management staffing during night

and weekend timeframes. CMS requires the use of a screening tool (such

as InterQual®) along with the complex medical judgment of an attending

physician to ensure that services billed are medically necessary. EdiPhy

 Advisors RNs are equipped, experienced and skilled in providing

accurate clinical insight and thorough documentation review to support

hospital efforts to operate in compliance with complex Medicare and

Medicaid rules and regulations. When facilities request nurse reviews,

our licensed staff extract the clinical data needed from medical records

 to evaluate if the patient meets Inpatient Status using evidence-based

criteria. If patient documentation does not support Inpatient Status,

the licensed clinical professional can seamlessly refer the case to a

Physician Advisor. EdiPhy Advisors manages and documents this process in

 compliance with health care law, as well as with CMS rules and

regulations.

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EdiPhy Advisors RNs provide expertise in Utilization Management

(UM). EdiPhy Advisors RNs are passionate about and skilled

in providing process review and consulting to facilitate improving case

management processes. Our licensed clinical staff support client

facilities by creating unique processes in support of existing

compliance goals as well as the implementation of inter-rater

reliability tools to validate process, evaluate staff compliance and

identify training needs.

 

Our seasoned licensed staff provide practical utilization review and

regulatory compliant solutions because we understand the requirements

and practical dilemmas of the health care delivery system. We also

understand that ongoing education of our own employees and of client

staff is critical to our mutual success. We coordinate education

sessions based on your client needs as well as broadly when regulatory

changes are announced.

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“It is not that I’m so smart. But I stay with the questions much longer.”

— Albert Einstein, 1921 recipient of Nobel Prize in Physics