Utilization Review Coordinator

Job Description

Job Description

Job Summary

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 as Revenue Cycle Manager :

• 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.

Requirements

Knowledge Skills and Abilities

Physical Requirements / Environmental Conditions

Perform the following with or without reasonable accommodations :

Minimum Education Degree in nursing, social work, mental health / behavioral sciences, or related field required; Master's degree preferred.

Minimum Work Experience A minimum of three years direct clinical experience in substance use disorders or mental health treatment setting, including one year of managing a related function preferred. Experience in patient assessment, ASAM, treatment planning and communication with external review organizations or comparable entities.

Required Licenses No Required License. LVN, RN, LMSW or applicable license preferred.

Benefits

Full-time employees are eligible for medical, dental, vision, company paid disability, 401(k) and a generous amount of paid time off.

Plum Creek Recovery Ranch is an equal opportunity employer and makes employment decisions exclusively on the basis of merit. We prohibit unlawful discrimination based on race, color, creed, sex, religion, age, national origin or ancestry, physical or mental disability, veteran status, marital status, medical condition including genetic characteristics, sexual orientation, gender identity, gender expression, transitioning status, or any other category protected by federal, state, or local laws.