Utilization Review Coordinator

Health Plans Inc•Remote, US,

15h•$80,000 - $90,000•Onsite

About The Position

HPI is a respected industry leader with over 44 years of experience, known for its innovation and adaptability in serving clients with health and benefit solutions. The company fosters a supportive and inclusive work environment where innovation thrives, investing in employee growth and well-being to ensure exceptional service. As a third-party administrator, HPI offers a suite of health and benefit solutions to employers nationwide.

Requirements

A minimum of three years of experience in an acute care clinical setting.
Active, current and unrestricted professional licensure as an RN (Registered Nurse) or LPN (Licensed Practical Nurse) in Massachusetts, Maine, New Hampshire or state of residency.
Proficient in Microsoft Office, including Word, Excel, Outlook and PowerPoint.

Responsibilities

Performs review of clinical information submitted to determine medical necessity, appropriate level of care and length of stay, based on standardized clinical criteria.
Renders positive determinations for cases that meet the criteria and refers all other cases for physician peer review.
Gathers relevant clinical information from appropriate health care providers.
Confirms medical necessity for selected procedures and services based on application of standardized clinical criteria to clinical information submitted; if a positive determination cannot be made based on the criteria, refers case to Peer Reviewer.
Conducts utilization management of appropriate level of care and length of stay using standardized clinical criteria.
Consults with Peer Reviewers when a positive determination cannot be made based on the standardized criteria or peer consult is needed to determine appropriateness of care beyond the standardized criteria.
Provides timely case screening to identify case management needs and generate appropriate referrals to Case Management or other appropriate clinical programs.
Ensures timely follow up on outstanding utilization management issues and inquiries.
Collaborates with health care providers to identify discharge needs in order to facilitate timely discharge to an appropriate level of care, with referral to Case Management as appropriate.
Communicates with providers and other health care professionals regarding the Utilization Management process.
Ensures case documentation follows policy and procedure.
Proactively manages professional growth by collaborating with Manager to identify as appropriate.
Demonstrates consistent and appropriate application of standardized criteria for purposes of interrater reliability.
Maintains satisfactory quality audit scores.
Manages work time and caseload efficiently.
Adherence to HIPAA policies and procedures.