Utilization Review Coordinator

Patient Transition And Utilization CoordinatorThe Patient Transition and Utilization Coordinator provides support services to the staff of the Case Management and Utilization Management departments. This position coordinates and implements the function of discharge planning for inpatient and outpatient needs. The coordinator assists with identifying and anticipating discharge needs for assigned patients and communicates and collaborates with the interdisciplinary team through verbal and written communications while maintaining strict confidentiality specific to communication, record keeping and coordination of services.The coordinator is also responsible for documentation in all areas of discharge planning. This position provides assistance to patients, families, and/or significant others by facilitating a safe discharge plan with guidance and direction from assigned Social Worker, Case Manager, and/or Director of Case Management as needed. Also responsible for obtaining insurance authorization for patients in the hospital, coordinating patient care as it relates to referrals and obtaining authorizations for services, as required by various payers. Works to obtain complex medically necessary authorizations, medical records or medical information.Essential Functions- Verifies insurance benefits and eligibility.- Obtains insurance authorizations for patients in the hospital.- Obtains demographic and insurance benefit information. Reviews patient's insurance and offers patient choice to patients and/or family based on insurance benefit and participating providers. Documents in the system.- Obtains and sends required medical records to support authorization and/or referral.- Documents authorization or denial in the electronic health record (EHR) and communicates with department or patient as indicated.- Coordinates services with other departments and providers such as home health and durable medical equipment providers.- Responsible for primary analysis of utilization-related projects.- Assesses situations, collects pertinent clinical and financial information, and formulates and implements plans to resolve issues.- Creates and maintains spreadsheets and reports.- Assists with the formulation of plans to resolve issues within the Case Management and Utilization Management arenas.- Escalates cases that have been denied by payer for peer-to-peer reviews.- Arranges transportation.- Participates in huddle with Case Managers and Social Workers to develop and implement a safe discharge plan.- Maintains current information on insurance requirements and community resources.- Takes into consideration any religious or cultural needs when discharge planning.- Tracks outcome measures such as avoidable days and makes follow-up calls to the patient.- Assists with Utilization Management services and Case Manager functions.- Reviews data and problem solves situations with Utilization staff, physician advisor, and pre-access as appropriate via fax, email, or portal.- Communicates transfer, referral, and discharge information to healthcare providers and agencies.- Coordinates the utilization review process, faxes records to utilization review agencies, and maintains database and document storage functions.- Monitors communications related to Utilization Management and responds appropriately.- Coordinates newborn notifications of admissions and prior authorizations; follows up for new insurance policy information.- Maintains denial worksheet and directs to appropriate department for further action.- Daily census review and updates of clinical information an indicated.- Utilizes verification portals to confirm proper insurance listing.- Sends clinical information to insurance payers to ensure authorization.Other Duties- Participates in departmental and association wide informational meetings and inservices, including staff meetings, association wide forums, and seminars.- Reviews department and association wide policies and procedures annually. Develops and maintains new policies and procedures as needed.Duties, responsibilities and activities may change or new ones may be assigned at any time with or without notice.Abilities- Must have experience with health insurance medical policies as well as insurance carrier benefit structures and the processes to obtain authorizations.- Must be able to type 35+ wpm.This position requires knowledge of general office equipment (including the nurse call system, telephone system, fax machine, copy machine, computer, and commonly used hospital programs) as well as excellent computer, communication, critical thinking, problem solving, leadership, supervisory, interpersonal skills, basic math skills, and the ability to exercise independent judgment.This position also requires knowledge of hospital equipment and programs, including all Hospital Information Systems and department specific equipment.- Must read, write, speak, and understand English.Work EnvironmentAt Summit Healthcare, our mission statement is that we are trusted to provide exceptional, compassionate care close to home. Our vision is to be the healthcare system of choice.To uphold our mission and vision statements, we expect all employees to practice SHINE Behavioral standards:- Always SHINE – show respect and be kind.- Always work together – we are on the same team.- Always serve others – no job is beneath you.- Always maintain high standards of quality and safety – best practice every time.- Always communicate clearly – be compassionate.- Always practice integrity – maintain confidentiality.- Always be accountable – take responsibility.- Always empower – create an environment of success.- Always excel – don't settle for mediocrity.- Always promote wellness – make choices for a healthy lifestyle.Physical DemandsExerts up to 20 lbs. of force occasionally, and/or up to 10 lbs. of force frequently, and/or a negligible amount of force constantly to move objects. Physical demands are in excess of those of Sedentary work. Light work usually requires walking or standing to a significant degree. Worker is exposed to extensive computer work.Required Education and Experience- High school diploma or equivalent.- Basic computer skills.- Basic medical terminology.- BLS/CPR certification required within 30 days of hire.Preferred Education and Experience- One-year experience with health insurance medical policies as well as insurance carrier benefit structures and the processes to obtain authorizations.- One-year medical business office functions experience or equivalent.- Associate's degree or documentation of certification/education in medical specialty.OSHA Exposure Category:Involves no regular exposure to blood, body fluids, or tissues, and tasks that involve exposure to blood, body fluids, or tissues and are not a condition of employment.This is a safety sensitive position.