UTILIZATION MANAGEMENT COORD Full Time Days

East Tennessee Children's Hospital Association•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 inpatient and observation admissions are pre-certified within required time frames. It also obtains and maintains pre-certification for inpatient, observation, and same-day surgery patients as required by policy. The coordinator reviews clinical information and communicates with insurers, physicians, practitioners, hospital departments, and outside reviewers. The position maintains utilization review records and related information in Meditech and other systems, participates in discharge planning and the Utilization Management Committee, processes appeals and retrospective eligibility reviews, and trains new utilization management coordinators. The role also supports regulatory compliance and helps maintain a courteous, professional, and confidential environment for patients, families, visitors, and coworkers.

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 using reference materials and resources.

Nice To Haves

Bachelor's degree preferred.

Responsibilities

Obtain initial pre-certification reviews for admissions through the emergency room and notify insurance companies of patient admissions.
Review and submit patient clinical information to insurance companies according to their policies.
Verify or obtain pre-certification for admissions directly from physician offices and for procedures requiring insurance pre-certification.
Perform extended-stay reviews for all patients.
Enter pre-certification numbers, approved days, extended approved days, and dates for the next clinical update in Meditech.
Maintain paper and electronic utilization review records.
Use Meditech, Trace Products, and insurance websites to obtain pre-certification.
Participate in discharge planning and actively participate in the Utilization Management Committee.
Process concurrent appeals for denied accounts while patients remain hospitalized, retrospective appeals for discharged patients, and second-level retrospective appeals when appropriate.
Process retrospective eligibility reviews for accounts assigned insurance.
Provide training to new utilization management coordinators on telephones, Meditech, Trace Products, and insurance websites.
Maintain program compliance with applicable laws and regulations.
Assist outside reviewers courteously.
Communicate patient account information with relevant departments and provide notification and clinical information to insurance companies.
Consult with and assist physicians, physician advisors, and practitioners, both internal and external.
Communicate professionally and courteously with patients, families, visitors, employees, insurance representatives, and other coworkers.
Maintain confidentiality of hospital and patient information and contribute positively to the hospital's customer service environment.
Use hospital resources and time respectfully and accountably, and accept other assignments as requested.