Utilization Review Coordinator conducts utilization reviews to determine if patients are receiving care appropriate to illness or condition. Monitors patient charts and records to evaluate care concurrent with the patients treatment. Being a Utilization Review Coordinator reviews treatment plans and status of approvals from insurers. Collects and complies data as required and according to applicable policies and regulations. Additionally, Utilization Review Coordinator consults with physicians as needed. May require a bachelor's degree. Typically reports to a supervisor. Typically requires Registered Nurse(RN). The Utilization Review Coordinator contributes to moderately complex aspects of a project. Work is generally independent and collaborative in nature. To be a Utilization Review Coordinator typically requires 4 to 7 years of related experience. (Copyright 2024 Salary.com)
This position plays a pivotal role in maintaining the fiscal health of the organization by ensuring the organization is fully reimbursed. Educating and consulting with the physician and the health care team to ensure accuracy of medical necessity criteria and to ensure timely and appropriate level of care is achieved. This requires excellent time management and prioritization skills along with collaboration with the provider and case management teams.
(30%)* Performs admission, concurrent and focused reviews using the medical necessity criteria and complies with CMS requirements. Perform admission/continued stay/discharge reviews when applicable.
(30%)* Determines necessity of second-level review and implement process per hospital policy. Provide educational information to physicians and other staff members as appropriate regarding medical necessity criteria, documentation guidelines, admission status, etc. and collaborates with the care team.
(15%)* Assist UR Committee and subcommittees in identifying areas of mis-utilization. Perform Hospital- wide quality assurance activities as requested.
(15%)* Facilitate appropriate insurance pre-certification, appropriate admission and status of patient.
Successfully negotiates patient status with the payer.
(10%)* Attend and participate in case management and discharge planning as required.
Complete denial appeals with physician and additional chart information, coordinate information and send in appeal. Coordinate with Appeals RN, as needed.
Maintain documentation of reviews, telephone contacts, appeal activity and progress.
Provides pertinent clinical data to designated outside agencies to assure compliance with their requirements.
Participates in Continuous Quality Improvement as required by the Medical Center and the job description.
Is skilled in determining the need for and implementing the hospital notice of non coverage.
UnderstandsandisaccountablefortheHealthSystem'scustomerservicestandards
Registered Nurse license required
Associate's Degree in Nursing required
Equivalent Experience: BSN Preferred
Three to five years clinical experience.
Prior UR experience and/or certification in U/R or Case Management preferred. Basic knowledge of coding preferred.
Exposure to stressful situations, including those involving public contact, as well as trauma, grief and death.
Is able to move freely about facility with or without an assisted device and must be able to perform the functions of the job as outlined in the job description.
Overall vision and hearing are necessary with or without assisted device(s).
Frequently required to sit/stand/walk for long periods of time. May require frequent postural changes such as stooping, kneeling or crouching.
Ability to handle multiple tasks, get along with others, work independently, regular and predictable attendance and ability to stay awake.
Overall dexterity is required including handling, reaching, grasping, fingering and feeling. May require repetition of these movements on a regular to frequent basis.
Physical Demand Level: Sedentary. Must be able to occasionally (0-33% of the workday) lift or carry 0-10 lbs.
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