UTILIZATION MANAGEMENT COORD Full Time Days

East Tennessee Children's Hospital•Knoxville, TN

About The Position

Under general supervision and according to established procedures, the Utilization Management Coordinator performs pre-certification and extended-stay reviews for patients at East Tennessee Children’s Hospital. The role ensures that all inpatient and observation admissions are pre-certified within required time frames. The coordinator also obtains and maintains required pre-certifications for inpatient, observation, and same-day surgery patients; maintains utilization review records; supports discharge planning; and participates in the Utilization Management Committee. This position reports to the Director of Health Information Management.

Requirements

Associate degree required; a bachelor's degree is preferred.
Degree in Nursing or Health Information Administration.
RN and/or RHIA required.
At least 2 years of Utilization Review experience.
Knowledge of medical terminology, anatomy and physiology, and pediatric nursing experience.
Excellent communication skills.
Detail-oriented, with organizational and time-management skills.
Proficiency with computers, word processing, and computer applications.
Problem-solving skills.
Proficiency in using reference materials and resources.

Nice To Haves

Bachelor's degree preferred.

Responsibilities

Obtain initial pre-certification reviews for admissions through the emergency room, notify insurance companies of patient admissions, and submit patient clinical information according to insurance policies.
Verify or obtain pre-certification for admissions directly from physician offices, perform extended-stay reviews, and obtain required pre-certification reviews for procedures.
Communicate patient-account information to relevant departments.
Enter pre-certification numbers, approved days, extended approved days, and dates for the next clinical update accurately in Meditech.
Maintain paper and electronic utilization review records.
Use Meditech, Trace Products, and insurance websites to obtain pre-certification, and participate in discharge planning.
Process concurrent appeals for denied accounts while patients remain hospitalized, retrospective appeals for discharged patients, and appropriate second-level retrospective appeals.
Process retrospective eligibility for accounts assigned insurance and participate in the Utilization Management Committee.
Train new utilization management coordinators on telephones, Meditech, Trace Products, and insurance websites.
Maintain program compliance with applicable laws and regulations.
Assist outside reviewers courteously.
Provide insurance companies with notifications and clinical information in a courteous, professional manner.
Consult, interact with, and assist physicians, physician advisors, and practitioners, both internal and external, in a courteous, professional manner.
Maintain confidentiality of hospital and patient information and treat patients, families, visitors, and coworkers with dignity, consideration, and courtesy.
Assist intradepartmental and other hospital coworkers as needed, communicate courteously with insurance representatives, and accept other assignments as requested.
Use hospital resources and time respectfully and accountably.