UR COORDINATOR

Universal Health Services•Guaynabo, PR

55d

About The Position

The Utilization Review Coordinator (URC) is responsible for initial clinical review. URC may approve requests for admissions, procedures, and services that meet clinical review criteria, but must refer requests that do not meet clinical review criteria to peer clinical review for certification or non-certification. Responsibilities and essential duties: Visits the hospital facilities or receives the documentation via fax and perform the initial review of the clinical information. Discuss the cases with the psychiatrists, psychologists, or social workers as appropriate to discuss medical necessity criteria for authorizations. Maintains the daily census of the assigned facilities. Responsible for making sure that the peer-to-peer discussion takes place. Issues the services authorizations after the review is completed. Maintains updated utilization review documentation in the platforms. Documents and reports in the system the ineligible cases. Provides the daily utilization data of the facilities assigned. Maintains a registry of all cases by facility/providers and account in the UMP platform. Participate in the departmental meetings. Keeps the specialization license and professional association membership effective. Complies with the continuing education hours that correspond to the specialization. Participates in the mandatory training courses, such as: the annual compliance plan, and updated clinical criteria. Inform the supervisor or human resources of any sanction or revocation of the license that affects the practice of the profession. Comly with standards of Service Excellence Program. Available to travel throughout Puerto Rico. Conduct prospective, concurrent, retrospective review and discharge planning. Responsible to evaluate the quality, medical necessity and services provided. Provide guidance to the non-clinical staff as needed. URC must provide written notices to the members and providers via fax, mail and/or secure email.

Requirements

Masters in Social Work, Psychology, Psychological Counseling, Counseling, Psychiatric Nursing, or Bachelor in Nursing.
Unrestricted valid and current active license for Social Work, Psychology, Counseling Psychology, Psychiatric Nursing, or bachelor's in nursing to practice in the Commonwealth of Puerto Rico
Valid membership for Social Work and Nursing.
Two or more years of experience in the health field
Kowledge in Microsoft Office

Nice To Haves

Preferable fully bilingual

Responsibilities

Visits the hospital facilities or receives the documentation via fax and perform the initial review of the clinical information.
Discuss the cases with the psychiatrists, psychologists, or social workers as appropriate to discuss medical necessity criteria for authorizations.
Maintains the daily census of the assigned facilities.
Responsible for making sure that the peer-to-peer discussion takes place.
Issues the services authorizations after the review is completed.
Maintains updated utilization review documentation in the platforms.
Documents and reports in the system the ineligible cases.
Provides the daily utilization data of the facilities assigned.
Maintains a registry of all cases by facility/providers and account in the UMP platform.
Participate in the departmental meetings.
Keeps the specialization license and professional association membership effective.
Complies with the continuing education hours that correspond to the specialization.
Participates in the mandatory training courses, such as: the annual compliance plan, and updated clinical criteria.
Inform the supervisor or human resources of any sanction or revocation of the license that affects the practice of the profession.
Comly with standards of Service Excellence Program.
Available to travel throughout Puerto Rico.
Conduct prospective, concurrent, retrospective review and discharge planning.
Responsible to evaluate the quality, medical necessity and services provided.
Provide guidance to the non-clinical staff as needed.
URC must provide written notices to the members and providers via fax, mail and/or secure email.