Utilization Review Coordinator, 40 Hour Days

UMass Memorial Health•Worcester, MA

1d•Onsite

About The Position

Functions as the coordinator of appropriate resources for the achievement of maximal clinical and financial patient outcomes. Collects data related to processes of care. Functions as the role of clinician, consultant, advocate, educator, and researcher for assigned service lines.

Requirements

Master’s degree in psychology, counseling, or Human Services or equivalent.
Minimum of 3-5 years direct clinical experience.
Must have excellent negotiation skills as well as good written and verbal communication skills.
Prior working knowledge of psych medications helpful.
Assertive and creative in problem solving, systems planning and patient care management.

Nice To Haves

Prior case management experience.
Word/Excel experience.
Experience with DSM4R coding and Allen Cognitive Level (ACL).

Responsibilities

Reviews data from admission screening to clarify admission diagnosis, establish appropriate length of stay and identify potential outliers.
Alerts the treatment team of patient coverage from third party payors. Elicits patient information from the treatment team that is detailed, descriptive, and indicative of current suicidal/ homocidality, or inability to care for self-based on their mental illness.
Communicates to third party payer on a regular basis the necessary information that justifies patient’s hospital level of care.
Provides admission, continued stay and discharge clinical review, including clinical reviews, to payers in accordance with established standards, procedures, and policies.
Collaborates with physicians and the interdisciplinary team to plan, coordinate, implement, and evaluate patient care.
Serves as a resource to the treatment team in relation to timely discharge planning.
Acts as a liaison to third party providers to ensure appropriate communication in regard to the implementation of patient’s treatment.
Reviews all charts daily for appropriate utilization of resources.
Clarifies third party coverage.
Communicate and facilitate the P2P process between physician advisor and payer physician advisor. Documents outcome.
Initialize and maintains utilization review worksheet.
Assess patients that current clinical presentation is congruent with hospital level of care. Contacts the treatment team as appropriate.
Collaborates with the third-party payers to anticipate denial of payment and proactively addresses issues contributing to a potential denial.
Collaborates with the Revenue Integrity and Denial teams to help to respond to insurance denials.
Documents Insurance denials, Avoidable days, and Administrative Necessary days in the patient EMR.
Complies with established departmental policies, procedures, and objectives.
Attends variety of meetings, conferences, seminars as required or directed.
Demonstrates use of Quality Improvement in daily operations.
Complies with all health and safety regulations and requirements.
Respects diverse views and approaches demonstrates Standards of Respect and contributes to creating and maintaining an environment of professionalism, tolerance, civility and acceptance toward all employees, patients, and visitors.
Maintains, regular, reliable, and predictable attendance.
Performs other similar and related duties as required or directed.