Clinical Utilization Review Coordinator

Coffey Health System•Burlington, KS

9d•Onsite

About The Position

The Clinical Utilization Review Coordinator evaluates the medical necessity, appropriateness, and efficient use of hospital resources for inpatient, observation, outpatient treatment room, outpatient surgery, and other applicable services. The position performs utilization review, coordinates prior authorizations, supports care coordination and discharge planning, abstracts quality data, and assists with scheduling and Swing Bed Coordination as needed. The Coordinator works with physicians, hospital departments, payers, and external review agencies to support appropriate levels of care, regulatory and payer compliance, effective transitions of care, quality outcomes, and appropriate reimbursement. The role monitors utilization trends and authorization outcomes, identifies opportunities for improvement, and prepares data, reports, and recommendations to support resource utilization, quality improvement, and patient safety. The position reports to the Chief Nursing Officer.

Requirements

Current RN or LPN license in the state of Kansas and graduation from an approved nursing program.
Three years of clinical nursing experience.
Current CPR certification.
Ability to read and comprehend simple instructions, short correspondence, and memos; write simple correspondence; and present information and respond effectively to questions from residents, family members, medical staff, employees, and the public.
Ability to perform basic arithmetic with whole numbers, common fractions, and decimals, and compute rates, ratios, and percentages.
Ability to apply common-sense understanding to written, oral, or diagram-form instructions and address problems involving a few concrete variables in standardized situations.
Ability to perform the listed essential duties satisfactorily, with reasonable accommodations where applicable.
Ability to meet the role's physical demands, including regular sitting, standing, walking, reaching, hand use, stooping, kneeling, crouching or crawling, and talking or hearing; occasional lifting up to 50 pounds and frequent or constant lifting of 25 pounds.
Vision abilities including close, distance, and color vision, depth perception, and ability to adjust focus.

Nice To Haves

One year of medical/surgical nursing experience preferred.
Utilization review experience desired.
Knowledge of DRG and ICD-10 coding, ISD-A criteria, and Medicare regulations preferred.

Responsibilities

Review inpatient, observation, outpatient treatment room, outpatient surgery, and other applicable services for medical necessity, admission status, level of care, and continued-stay appropriateness using established criteria and payer requirements.
Review clinical documentation for regulatory and payer compliance, identify cases that do not meet criteria, and coordinate referrals to the physician advisor or designated medical staff for further review.
Coordinate and obtain prior authorizations; communicate with payers and external review agencies about authorizations, medical necessity, level of care, continued stays, and denials.
Assist with discharge planning, care coordination, and transitions of care in collaboration with physicians, nursing, Social Services, Case Management, and other departments.
Assist with Swing Bed Coordination and serve as backup Swing Bed Coordinator when needed.
Assist with scheduling services, procedures, or appointments as needed.
Perform quality data abstraction in collaboration with the Director of Quality and Risk Management and report quality, infection prevention, patient safety, risk management, and other concerns identified through record reviews.
Compile and analyze utilization data, authorization outcomes, denials, trends, logs, statistics, and other required reports; provide recommendations for resource utilization, reimbursement, documentation, and quality improvement.
Collaborate with the physician advisor, medical staff, Business Office, Patient Registration, and other stakeholders to address utilization concerns, documentation needs, payer requirements, and improvement opportunities.
Provide education to hospital employees and medical staff about utilization review, medical necessity criteria, prior authorization requirements, documentation standards, and regulatory or payer changes.
Maintain current knowledge of utilization management standards, Medicare regulations, payer policies, review criteria, DRG methodology, ICD-10 coding, and other relevant requirements.
Maintain patient confidentiality and comply with applicable privacy, security, regulatory, and organizational requirements.
Demonstrate professional conduct, effective communication, dependable attendance, and cooperation with patients, families, physicians, coworkers, payers, and external agencies.
Maintain professional growth through continuing education and training; perform other duties as assigned.