PRN UR Coordinator

Utilization Review Coordinator

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 hospital stays. Completing data collection of demographics, claim and medical information; non-medical analysis; and outcomes reporting. May consult with staff as needed.

Essential Duties:

• 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.

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.