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:
• Evaluate patient medical records to assess the appropriateness and quality of care provided.
• Verify the accuracy and completeness of documentation to support medical necessity.
• Analyze treatment plans and interventions to ensure they align with patient needs and best practices.
• Collaborate with healthcare providers to make recommendations for adjustments or improvements in treatment plans.
• Verify insurance coverage and benefits to determine eligibility for services.
• Communicate with insurance providers to obtain authorization for services as needed.
• Conduct utilization reviews to monitor and optimize the use of healthcare resources.
• Identify and address any utilization patterns that may indicate inefficiencies or deviations from standards of care.
• Maintain accurate and detailed records of utilization review activities and outcomes.
• Prepare reports and summaries of findings for internal review and compliance purposes.
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.
Education and/or Licensure – Bachelors.
Experience – 1 year of relatable experience required, 3 preferred
Additional Requirements – None.
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 work competently with computer-based charting and other clinical and non-clinical software programs.
• Adaptability to change and good organizational skills required. Ability to read and communicate effectively in English.
• Can be expected to do presentations as directed. Working knowledge of criteria for Medicare, Medicaid, HMO, and private insurance carrier's coverage details.
• Ability to advocate for patients. Ability to operate office equipment. Possess critical thinking skills.
• Leadership skills required for role include effective mentoring, coaching, counseling, time management, problem solving, and strategic planning.
• Demonstrates initiative and proactive approach to problem resolution.
• Ability to effectively interact with insurance companies and community healthcare recourses.
• Ability to work in a stressful, fast paced environment. - 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.
401K, Medical/Dental insurance, FMLA and Short-Term Disability
- 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)
