The 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 patients' treatment. Reviews treatment plans and status of approvals from insurers. Responsible for monitoring adherence to the hospital's utilization review plan to ensure the effective and efficient use of hospital services. Monitors the appropriateness of hospital admissions and extended hospitals stays. Completing data collection of demographics, claim and medical information; non-medical analysis; and outcomes reporting. May consult with staff as needed.
Essential Duties:
- Collaborate and set standards with registered nurse (RN) case managers (CMs) and outcome managers to ensure that all hospitalized patients have the correct admission status (inpatient, outpatient short stay, observation status) so that the appropriate claim can be submitted to commercial and government payers.
- Complete short stay work-queue reviews and track and trend results for reporting and education purposes. Identify opportunities for process and system improvement and initiate and lead performance initiatives as indicated.
- Identify and facilitate resolution of system process problems impeding UM functions. Identify and resolve delays and obstacles as appropriate.
- Establishes and maintains efficient methods of ensuring the medical necessity and appropriateness of all hospital admissions
- Validates authorization requests are complete or requests additional data as necessary
- Performs concurrent reviews for patients to ensure that extended stays are appropriately documented in patient's medical records
- Reviews notices of potential denials and respond appropriately; i.e. facilitate Physician to Physician appeals when appropriate and assist with construction of appeal letters
- Tracks denial information for reporting to Quarterly UR Committee
- Maintains liaison with the Social Services department to facilitate timely discharge planning
- Enters complete and accurate documentation into the system describing all patient related admitting/registration activities
- Follows all regulatory policies and procedures, privacy and security standards in accordance with government agencies including HIPPA requirements
- Performs other duties as required.
- Upholds the Organization's ethics and customer service standards
This job description is not intended to be all-inclusive. Employee may perform other related duties to meet the ongoing needs of the hospital. Duties may be modified or changed with or without notice.
Requirements
Education and/or Licensure - Highschool Diploma or equivalent.
Additional Requirements - None.
Experience - 3-5 years Admitting or Financial Counseling preferred.
Knowledge Skills And Abilities
- Must have basic PC skills that include a combination of working in a Windows Operating System and Microsoft Outlook, Word and Excel
- Has knowledge of governmental and managed care payer requirements.
- Demonstrates understanding of the various "Self-Pay" account classifications and their applicable patient statement processes.
- Understands the data elements required to generate a clean bill.
- Understands the importance of maintaining confidentiality; able to maintain confidentiality under HIPAA standards
- Must have the ability to exercise a high degree of diplomacy and tact; excellent customer services and interpersonal communication skills; Cultural sensitivity and demonstrated ability to work with diverse people groups
- Well-developed verbal and written communication skills in English; Additional language abilities desirable
- Knowledge of basic math and modern office procedures
- Ability to work well under pressure with minimal supervision.
- Ability to remain seated at switchboard for long periods of time without significant discomfort or distress
- Ability to effectively interact with persons of widely diverse roles, backgrounds, cultures, and socio-economic classes, those in crises or resistant or negative toward organization
Physical Requirements/Environmental Conditions
Perform the following with or without reasonable accommodations:
- Ability to stoop, kneel, crouch, crawl, reach, stand, walk, push, pull, lift, grasp, and be able to perceive the attributes of objects such as size, shape, temperature, and/or texture by touching with skin, particularly that of the fingertips.
- Ability to express and exchange ideas via spoken word during activities in which they must convey detail or important spoken instructions to others accurately, sometimes quickly and loudly.
- Hearing to perceive the nature of sound with no less than 40 db loss @ Hz, 1000 Hz, and 2000 Hz with or without correction; ability to perceive detailed information orally and make fine discriminations in sound.
- Perform repetitive motions with wrists, hands, and fingers. Individual must be able to exert up to 100 pounds of force occasionally and to be able to lift, carry, push, pull, or otherwise move objects.
- Work requires a minimum standard of visual acuity with or without correction that will enable people in the role to complete administrative and clerical tasks, as well as inspect and analyze
- Must be able to work and concentrate amidst distractions such as noise, conversation and foot traffic; ability to handle interruptions often and be able to move from one task to another
- While worker may possibly be subjected to temperature changes, the worker is generally not substantially exposed to adverse environmental conditions as the work is predominantly inside
Benefits
- Health Insurance
- Vision Insurance
- Dental Insurance
- 401K Retirement Plan
- Healthcare Spending Account
- Dependent Care Spending Account
- PTO Plan with Holiday Premium Pay
- Life Insurance (Supplemental Life, Term, and Universal plans are also available.)
- Short and Long-Term Disability (with additional buy-in opportunities)
