Utilization Review Coordinator (8 AM - 5 PM)

VieMed Healthcare•Lafayette, LA

3d•Onsite

About The Position

The Utilization Review Coordinator conducts clinical reviews of patient medical records and referral documentation to assess whether records support prescribed therapies, ordered equipment and supplies, and applicable coverage requirements. The role applies professional nursing knowledge to evaluate clinical findings, medical necessity, and documentation completeness, and provides recommendations about referral readiness and next steps. It evaluates records against Medicare, Medicaid, and commercial-payer requirements before reimbursement submission and follows applicable regulations, payer requirements, and company procedures. The coordinator documents findings, deficiencies, recommendations, and referral status in designated computer systems; communicates documentation gaps to appropriate parties; and escalates complex clinical questions, compliance concerns, and other matters requiring further review. The position requires handling Protected Health Information in accordance with HIPAA policies and procedures. It is performed in an office environment, normally Monday through Friday, 8:00 a.m. to 5:00 p.m. Weekend work, overtime, or on-call coverage may be required based on business needs.

Requirements

Current, active Registered Nurse (RN) license in good standing.
Clinical nursing experience with the ability to review medical records, interpret physician documentation, and apply professional nursing judgment.
Ability to apply nursing knowledge and clinical judgment when assessing the completeness and clinical relevance of medical documentation.
Ability to read and interpret diagnoses, physician orders, progress notes, diagnostic testing, treatment plans, and other clinical records.
Working knowledge of medical terminology and common respiratory and durable medical equipment (DME) therapies.
Understanding of medical insurance concepts and ability to learn and apply Medicare, Medicaid, and commercial-payer documentation requirements.
Strong attention to detail and ability to identify incomplete, conflicting, or insufficient documentation and clearly communicate gaps.
Effective written and verbal communication skills for professional interactions with physicians, healthcare providers, insurers, patients, colleagues, and leadership.
Ability to manage multiple chart reviews, prioritize workload, meet turnaround expectations, and maintain accurate documentation.
Ability to work independently, exercise sound clinical judgment, and collaborate across operational departments.
Proficiency with electronic medical records, patient and referral databases, and Microsoft Office applications, including Outlook, Word, and Excel.
Professionalism, accountability, initiative, and consistent productivity.
Availability to work Monday through Friday during an agreed-upon shift; weekend work, overtime, or on-call coverage may be required based on business needs.

Responsibilities

Review patient medical records and referral documentation to determine whether they support prescribed therapies, ordered equipment and supplies, and coverage requirements.
Review physician orders, progress notes, histories and physicals, diagnostic information and test results, hospital records, and other relevant clinical documentation.
Identify missing, incomplete, inconsistent, or unclear documentation and communicate specific deficiencies or clarification needs to appropriate parties.
Apply nursing knowledge to evaluate diagnoses, symptoms, treatment history, medical-necessity indicators, and the relationship between clinical findings and requested therapies or equipment.
Recommend referral readiness, additional documentation requirements, and appropriate next steps based on clinical chart-review findings.
Evaluate clinical documentation against applicable Medicare, Medicaid, and commercial-payer coverage criteria before reimbursement submission.
Maintain compliance with governmental regulations, payer requirements, and company Intake, Billing, and Compliance procedures.
Document review findings, identified deficiencies, recommendations, and referral status accurately in the designated computer system.
Escalate complex clinical questions, documentation concerns, potential compliance issues, and other matters requiring further review to the Intake Manager, Intake Supervisor, or appropriate leadership.
Perform other assigned responsibilities and projects.
Protect PHI and follow applicable HIPAA policies and procedures.