FT Utilization Review Coordinator

POSITION SUMMARY:

Performs inpatient, outpatient, concurrent admission and procedure reviews using the standardized level of care criteria selected by the facility to determine necessity, appropriateness, and efficiency of admissions, procedures and extended duration reviews. Obtains authorizations for outpatient and inpatient procedures, inpatient admissions and observation beds. Obtains retro-authorizations when requested by billing/financial services. Performs appeals for denials and arranges physician peer to peer reviews when appropriate. Promotes good public relations through contacts with physicians, fellow employees and patients in which services are being rendered. Maintains appropriate documentation for all Utilization Review (UR) transactions. Responsible for UR Performance Improvement (P.I.) Analysis and preparation of reports to be presented to P.I. Committee. Leads the UR Committee and works with the UR Medical Director. Communicates with a variety of clinical disciplines including physicians, advanced practitioners and nursing staff to clarify medical necessity. Must be able to work well in fast-paced, continual changing environment, with minimal supervision and ability to problem solve through respectful communication under the direction of the Case Management director.

PRIMARY RESPONSIBILITIES & AUTHORITIES:

• To receive admission requests and services to be performed in an observation, inpatient or swing bed setting.
• Performs admission, concurrent and retro reviews using the current Level of Care criteria standards selected by the facility.
• Obtains in-patient, out-patient (observation) and swing bed requisite information about the patient and proposed treatment or procedure.
• Evaluates the patient insurance coverage, and proposed procedure for the appropriate care setting, contacts insurance for authorization of procedure, outpatient or inpatient hospitalizations.
• Triage patients to appropriate level of care through discussions with attending physician and nursing staff. Serves as a UR resource for members of the medical and hospital staff.
• Interfaces with external reviewing/paying agencies regarding review of specific cases for medical necessity and appropriateness.
• Consults and refers cases for physicians review by providing accurate, complete and objective information regarding the patients clinical situation and plan of care.
• Screens patients for the need for continuing care assistance and makes referrals to social service/discharge planning for follow up as needed.
• Works with discharge planning personnel and swing bed coordinator to facilitate continuing care planning including transfer to the appropriate level of care as needed.
• Must have full knowledge and ability to access and assign ICD-10-CM and CPT codes for proper diagnosis and procedures.
• Maintains confidentiality of all information obtained during performance of job duties, as in accordance with HIPPA rules and regulations.
• Maintains work logs of reviews of admission, procedures, concurrent or retrospective reviews.
• Performs Utilization Review P.I. analysis. Provides quarterly reports to P.I. Coordinator and P.I. Committee.
• Leads the Utilization management committee meetings.
• Maintains a clean and well-organized work area.

OTHER DUTIES AND RESPONSIBILITIES:

• Other duties and responsibilities as directed by the Case Management Director.
• Assists CM in obtaining authorization for swing bed level of care and other outpatient procedures such as ambulance transfers, etc. Assists with swing bed admissions as needed or requested.
• Other duties as assigned.
• Meet requirements for CEUs to keep certification current.
• Assists with discharge/transfer process when needed.

MINIMUM QUALIFICATIONS (EDUCATION, EXPERIENCE, SKILLS, ABILITIES):

Registered Nurse/Licensed Practical Nurse, Registered Health Information Technologist, and/or Certified Professional in Utilization Review required with experience in utilization management and review functions. Thorough knowledge of medical terminology, clinical and surgical data interpretation required. Basic knowledge of medical coding and patient assessment planning preferred.

Knowledge base of various computer software and use of computers, including keyboarding/typing skills required.

Excellent communication skills, verbal and written are mandatory. Excellent customer service and problem-solving skills essential. Must display an ability to build positive relationships with medical staff.

OTHER SPECIAL REQUIREMENTS (LICENSES, CERTIFICATIONS, REGISTRATIONS, ETC.)

Membership with a utilization review or case management professional organization is encouraged.

PHYSICAL DEMANDS:

May remain seated for extended periods of time. Use of telephone for long periods of time (earpiece available for use). Some walking required for reviews and errands. Ability to use hands for typing, taking notes, and messages is required. Interactions with patients and their caregivers/family members will occur.

WORK ENVIRONMENT:

Well lighted, ventilated area within the hospital. Shared office space with other case management personnel.