Utilization Review Coordinator (8 AM - 5 PM)

VieMed Careers•Lafayette, LA

2d•Onsite

About The Position

The Utilization Review Coordinator conducts clinical reviews of patient medical records and referral documentation to assess whether the documentation supports prescribed therapies, ordered equipment and supplies, and applicable coverage requirements. The role applies professional nursing knowledge and clinical judgment to assess diagnoses, symptoms, treatment history, medical-necessity indicators, and the connection between clinical findings and requested therapies or equipment. It evaluates documentation against Medicare, Medicaid, and commercial payer criteria and applicable regulations and procedures, and records findings and referral status in designated systems. The coordinator identifies and communicates documentation gaps, recommends referral readiness and next steps, and escalates complex clinical questions, potential compliance concerns, and other issues requiring additional review. The role involves handling Protected Health Information (PHI) and requires following HIPAA Privacy Rule requirements and company policies to protect it. This position works in an office environment during normal business hours, 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. Duties and responsibilities may change with or without notice.

Requirements

Current, active Registered Nurse (RN) license in good standing.
Clinical nursing experience and demonstrated ability to review medical records, interpret physician documentation, and apply professional nursing judgment.
Ability to apply nursing knowledge and sound clinical judgment to evaluate 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 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 documentation that is incomplete, conflicting, or insufficient and clearly communicate the specific gap.
Effective written and verbal communication skills for professional communication with physicians, healthcare providers, insurers, patients, colleagues, and leadership.
Ability to manage multiple chart reviews, prioritize workload, meet established turnaround expectations, and maintain accurate documentation.
Ability to work independently, exercise sound clinical judgment, and collaborate effectively across operational departments.
Proficiency with electronic medical records, patient and referral databases, and Microsoft Office applications, including Outlook, Word, and Excel.
Demonstrated 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

Conduct clinical reviews of patient medical records and referral documentation to assess support for prescribed therapies, ordered equipment and supplies, and coverage requirements.
Review physician orders, progress notes, histories and physicals, diagnostic information, test results, hospital records, and other relevant clinical documentation.
Identify incomplete, inconsistent, unclear, or missing clinical 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 chart-review findings.
Evaluate clinical documentation against applicable Medicare, Medicaid, and commercial payer coverage criteria before submission for reimbursement.
Maintain compliance with governmental regulations, payer requirements, and VieMed Intake, Billing, and Compliance procedures.
Document clinical review findings, deficiencies, recommendations, and referral status accurately in the designated computer system.
Escalate complex clinical questions, documentation concerns, potential compliance issues, and other matters requiring additional review to the Intake Manager, Intake Supervisor, or appropriate leadership.
Protect PHI by strictly following applicable policies and procedures, including HIPAA Privacy Rule requirements.
Perform other responsibilities and projects as assigned.