The Basics

This second of the trio of standards defining the role of non-clinicians in utilization management assures that there is adequate clinical oversight of the non-clinicians.  Simple in its content, this standard requires the organization to have licensed professionals available to the administrative people conducting the initial screening.

This access need not be face-to-face, but it must be real-time.  In other words, if the clinician(s) overseeing the non-clinical staff conducting initial screening are not in the same office, the non-clinical staff members must be able to pick up a phone and get a clinician on the line immediately.  

Management Tips

The key management task for this standard is to make sure that your P&Ps, as well as the job descriptions for both clinical and non-clinical staff members, are crystal clear in defining the roles of staff members.  They also should be clear about how clinical staff members oversee the initial screening process.

URAC Accreditation Tips

At the desktop review stage, your organization will submit your P&Ps and UM staff members' job descriptions.  An organization chart that shows reporting responsibilities will help the reviewer see the key relationships in the oversight of the initial review function.  In addition, any applicable scripts should be submitted.  

However, the key to passing this standard will come in the onsite inspection and the interviews of clinical and non-clinical staff members by the URAC reviewer.  Those conversations, as well as the physical space itself, will provide the essential confirmation that the clinical staff members are appropriately available for consultation.  Make sure your staff training emphasizes this consultative relationship.