Utilization Review Coordinator

Responsibilities

• Coordinate patients’ services across the continuum of care by promoting effective utilization
• Monitor health resources and elaborate with multidisciplinary teams
• Filing documents as needed
• Initial Precertification with payors
• Concurrent Clinical review with payors
• Document in the electronic system daily in real time
• Admission audit
• Ensures that CON’s/RON’s and CMS certifications are completed by provider
• Consistently demonstrates professionalism with all internal and external customers
• Communicates effectively with all staff and patients
• Maintains knowledge of current trends and developments in the field
• Maintains a professional approach with
• Cooperates and maintains good rapport with nursing staff, medical staff, and other departments
• Sets and maintains productive working relationships
• Seeks guidance and remains knowledgeable of, and complies with, all applicable federal and state laws, as well as hospital policies
• Complies with hospital expectations regarding ethical behavior and standards of conduct
• Complies with federal and hospital requirements in the areas of protected health information and patient information
• Reconsiderations, assists with appeals as needed, arrange peer to peer level reviews, and report the outcomes to the VP of Care Management and Team
• Provides education to nursing staff, leadership team, and providers regarding documentation
• Actively works with the business office regarding resolution of appeals/denials and retrospective reviews

Requirements

• Bachelor's in Behavioral Health, Social Work, Counseling, Nursing or Psychology required
• Master's degree preferred
• Minimum of 2 years of utilization review experience in a hospital setting required
• Minimum of 2 years of case management experience, including discharge planning in a hospital setting required
• Certified Case Manager (CCM) or Accredited Case Manager (ACM) preferred
• Basic Life Support (BLS) and Handle with Care (HWC) obtained during orientation, if applicable

Skills

• Strong knowledge of medications
• Exceptional time management
• Data entry skills
• Communication skills