PRN Utilization Review Coordinator
About The Position
The PRN/as-needed Utilization Review Coordinator performs internal and external record reviews as part of daily department operations. The role coordinates certification and utilization reviews with admissions, insurance companies, and other payers; obtains authorizations for services not covered under per diems; and documents review outcomes and authorizations in certification records. The coordinator maintains ethical review practices and communicates relevant case status, authorization, and peer-review information to physicians and treatment teams. The position also supports regulatory and payer survey preparedness, audits and reviews charts based on data collection reports, communicates charting deficits to the team before reviews, and ensures review information is documented in the chart. The coordinator may educate teams and patients about benefits, discharge options, and the organization’s continuum of care, and attends team or staff meetings as clinically indicated. Shifts needing coverage are Monday through Friday, 8:00 a.m. to 5:00 p.m.
Requirements
- Master’s degree and licensure in a clinical discipline, such as Social Work, Psychology, Nursing, or another healthcare field; equivalent years of specific utilization review experience may be substituted for licensure.
- License or certification: LPC, LMSW, RN, or LCSW.
- Three years of experience in a health care field.
- At least one year of full-time experience performing insurance reviews, either pre-certification and/or concurrent reviews.
- Proficiency using computers, calculators, phones, fax machines, and copy machines.
- Basic knowledge of Microsoft Office, health insurance and collection regulations, team concepts and performance improvement, human behavior, and psychopathology.
- Basic knowledge of managed care concepts, social and family systems, and treatment modalities.
- Knowledge of DSM IV-TR.
Responsibilities
- Perform internal and external record reviews as part of daily department operations.
- Cooperate with Admissions to complete certifications as needed and document outcomes in certification records.
- Perform concurrent utilization reviews with insurance companies and relevant payers, documenting outcomes in certification records.
- Obtain and document authorization for services not covered under per diems and communicate directly with physicians or clinicians.
- Maintain appropriate and ethical performance of internal and external reviews.
- Develop and maintain professional relationships with treatment team members to support Utilization Management.
- Communicate assigned case status to appropriate treatment team members, with mandatory reporting to the physician or team designee.
- Communicate the need for peer reviews between physicians and payers, facilitate them as needed, and complete documentation.
- Attend team or staff meetings according to program schedules, as clinically indicated.
- Educate teams and patients as needed about benefits related to discharge options and use of the continuum of care.
- Assist with preparedness for surveys by regulatory agencies and payers.
- Audit and review charts, with depth and intensity guided by data collection reports.
- Communicate charting deficits to the team before completing reviews.
- Ensure all review information is in the chart before completing a review.
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What This Job Offers
Career Level
Mid Level
