Utilization Review Coordinator

Job Description

Job Description

Qualifications :

Education : Must have an associate degree or bachelor’s Degree

Licensure : Licensed RN or LPN is preferred

Experience : Must have one (1) year experience in the Utilization Review process and / or two (2) years’ clinical experience in a psychiatric facility.

Additional Skills : Highly proficient in Microsoft Office.  Strong organizational skills, communication skills and ability to perform detailed work.  Ability to use the English language and medical terminology effectively and to understand / carry out complex oral and written instructions within a prescribed routine.

STANDARDS OF PERFORMANCE :

• Conduct admission and continued stay reviews according to the Utilization Review Plan diagnostic criteria.
• Works closely with the Medical Director, Clinical Director, and all clinical staff to ensure that sufficient documentation is present to justify the clinical necessity and appropriateness of admission and continued stay.
• Compiles statistical reports and submits monthly to the Committee of the Whole.
• Evaluates and recommend strategies to improve the efficiency with which services are provided and detect and eliminate under or over utilization.
• Review cases with insurance / managed care companies / out-of-state entities to include pre-certification, admissions reviews, and continued stay reviews.
• Work with Medical Records regarding documents sent to any insurance / managed care company.
• Review charts daily, report any deficiencies to the appropriate staff, and assisting with getting those deficiencies corrected.
• Maintain a positive work atmosphere by behaving and communicating in a manner that promotes cooperation and teamwork with co-workers, supervisors, patients, and visitors.
• Maintain a safe work environment by following safety practices within the center and immediately reporting any safety concerns / issues to the Director of Plant Operations and / or Quality Coordinator.
• Conduct other duties as assigned by the Facility CEO or other designee.
• Knowledge of and ability to perform the full admission process, including but not limited to admission phone calls; referral source communication; verification of benefits; copying, filing, faxing and mailing of confidential documents.
• Assist case workers, families / guardians, and referral sources with the admissions process, admissions phone calls; referral source communications; verification of benefits; coping, filing and mailing of confidential documents.
• Participates as an integral member of the treatment team including attendance and knowledge of scheduling of treatment team reviews, special case reviews, and treatment formulation. In addition, work with parents, guardians and family members to encourage active involvement in treatment of the residents and continuation of active insurance benefits.
• Attends meetings, prepares reports, and follows policy and procedures to include patient rights, confidentiality, privacy and the code of ethics.  Participates in performance improvement activities to include staff development and completes all required annual training.
• Demonstrates the ability to oversee the Discharge Planning process for each resident to ensure that the process is complete and timely.
• Demonstrates the ability to keep all information updated in the computer system regarding insurance authorizations and assists Corporate in any billing issues.

WORK ENVIRONMENT :

The work environment for this position is a residential and child adolescent facility setting.  While performing the duties of this job, the employee will be exposed to clients who may ask inappropriate personal questions, display socially unacceptable personal behaviors, use profanity and sexually explicit phrases, make insulting remarks or threats regarding appearance, age, sex, or race, and exhibit defiance, dishonesty, and assaultive or self-destructive behaviors.  The employee is occasionally exposed to outside weather conditions and may be subject to occasional local travel as required by facility needs.  The noise level in the work environment is usually moderate. Job hazards encountered include exposure to body fluids, bodily injury, electrical shock, mechanical failure, exposure to toxic chemicals, radioactive chemicals, physical / mental stress, and irregular hours.  Patient verbal or physical assault is possible.

MENTAL REQUIREMENT :

Ability to exercise self-control in potentially volatile situations.  Must be able to work and concentrate amidst distractions such as noise, conversation, and foot traffic.  Must be flexible and able to complete multi-tasks without overwhelming frustration.

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