Utilization Review Coordinator

Job Description

Job Description

Utilization Review Coordinator

Location: Everwell Port St. Lucie Hospital, Inc

Position Summary

Everwell Port St. Lucie Hospital is seeking a detail-oriented Utilization Review Coordinator to coordinate insurance reviews, monitor patient authorizations, and support effective communication between the hospital, physicians, and insurance providers.

Key Responsibilities

• Review all patients’ admissions on a daily basis to determine necessity and appropriateness of placement services as outlined in Plans and Procedures.

• Assigns continued stay reviews according to criteria; reviews continued stay at least every ten (10) to fourteen (14) days and certified pursuant to approved criteria.

• Maintains a system for monitoring all admissions to assure timely reviews; collects and records all necessary information/data for review of admission, continued stay, and utilization of services.

• Reviews patient records upon request of insurance companies and communicates patient condition and treatment to external utilization review offices.

• Contacts physicians and primary Nurses for clarification of information as necessary.

• Assures appropriate Authorization of Release of Information forms are obtained prior to releasing information to insurance companies.

• Completes mental health treatment reports and other reports, including appeal letters, required by insurance companies for review of patient care and treatment as requested.

• Monitors information that is copied and sent per request to insurance companies for inpatient and assures that only required information is disseminated.

• Contacts physicians, primary Nurses and other appropriate staff regarding potential problems or questions related to documentation of patient care issues.

• Coordinates and schedules all PRO reconsideration hearings and schedules appropriate staff to attend hearings.

• Coordinates the assemblage of records for review by Federal State, Professional and appropriate hospital groups.

• Performs special projects or other related work as required or requested.

• Shows ability to communicate in a clear and concise manner.                       

• Demonstrates ability to work with others.

• Adapt to changing situations or work assignments.

• Demonstrates willingness to rotate to other areas of hospital within the limits of preparation and skill level.

• Conform to uniform and dress code, personal hygiene and good grooming.

• Wear and properly display name badge.                                                                 

• Positively respond to guidance or counseling and attempts to benefit by it.

• Adept in identifying potential problems within the department and seeks management guidance.

• Demonstrates excellent organizational skills and originator of new ideas and methods.

• Use verbal and non-verbal communication with others, i.e., courtesy, tone of voice, facial expressions, gestures, etc.

• Demonstrates an understanding of and adherence to the Code of Conduct

• Conduct reflects Oglethorpe’s values and a commitment to the Code of Conduct

Qualifications and Education

• RN, LPN or Master's Level Clinician with experience

• CPR Certification required

• Minimum 2 years of healthcare experience preferred

• Knowledge of utilization review processes and medical terminology

• Experience working with insurance companies and behavioral health

  documentation preferred

• Ability to use data collection techniques, and statistical computations.

• Strong communication, organizational, and analytical skills

• Familiarity with DSM criteria and healthcare compliance standards preferred

• Thorough knowledge of effective and appropriate charting principles

  Work Environment

  • Primarily indoor, temperature-controlled healthcare environment

  • Collaborative team-focused setting

    Benefits

  • Medical, Dental and Vision insurance

  • 401K

  • PTO and Sick time

  This position requires a pre-employment Level 2 Background check: