Utilization Review Coordinator

Perimeter Healthcare•Jackson, TN

1d•Onsite

About The Position

The Utilization Review Coordinator is responsible for conducting admission and continued stay reviews, working closely with clinical staff and the Medical Director to ensure documentation justifies the necessity and appropriateness of care. This role involves compiling statistical reports, recommending strategies to improve service efficiency, and reviewing cases with insurance companies. The coordinator also works with Medical Records, reviews charts daily, and maintains a positive and safe work atmosphere. Additional duties include managing the full admission process, assisting with case management, participating in treatment team activities, overseeing discharge planning, and updating the computer system with insurance authorization information.

Requirements

Must have an associate degree or bachelor’s Degree
Must have one (1) year experience in the Utilization Review process and/or two (2) years’ clinical experience in a psychiatric facility.
Highly proficient in Microsoft Office.
Strong organizational skills, communication skills and ability to perform detailed work.
Ability to use the English language and medical terminology effectively and to understand/carry out complex oral and written instructions within a prescribed routine.
Ability to exercise self-control in potentially volatile situations.
Must be able to work and concentrate amidst distractions such as noise, conversation, and foot traffic.
Must be flexible and able to complete multi-tasks without overwhelming frustration.

Nice To Haves

Licensed RN or LPN is preferred

Responsibilities

Conduct admission and continued stay reviews according to the Utilization Review Plan diagnostic criteria.
Work closely with the Medical Director, Clinical Director, and all clinical staff to ensure that sufficient documentation is present to justify the clinical necessity and appropriateness of admission and continued stay.
Compile statistical reports and submit monthly to the Committee of the Whole.
Evaluate and recommend strategies to improve the efficiency with which services are provided and detect and eliminate under or over utilization.
Review cases with insurance/managed care companies/out-of-state entities to include pre-certification, admissions reviews, and continued stay reviews.
Work with Medical Records regarding documents sent to any insurance/managed care company.
Review charts daily, report any deficiencies to the appropriate staff, and assist with getting those deficiencies corrected.
Maintain a positive work atmosphere by behaving and communicating in a manner that promotes cooperation and teamwork with co-workers, supervisors, patients, and visitors.
Maintain a safe work environment by following safety practices within the center and immediately reporting any safety concerns/issues to the Director of Plant Operations and/or Quality Coordinator.
Conduct other duties as assigned by the Facility CEO or other designee.
Perform the full admission process, including but not limited to admission phone calls; referral source communication; verification of benefits; copying, filing, faxing and mailing of confidential documents.
Assist case workers, families/guardians, and referral sources with the admissions process, admissions phone calls; referral source communications; verification of benefits; coping, filing and mailing of confidential documents.
Participate as an integral member of the treatment team including attendance and knowledge of scheduling of treatment team reviews, special case reviews, and treatment formulation.
Work with parents, guardians and family members to encourage active involvement in treatment of the residents and continuation of active insurance benefits.
Attend meetings, prepare reports, and follow policy and procedures to include patient rights, confidentiality, privacy and the code of ethics.
Participate in performance improvement activities to include staff development and complete all required annual training.
Oversee the Discharge Planning process for each resident to ensure that the process is complete and timely.
Keep all information updated in the computer system regarding insurance authorizations and assist Corporate in any billing issues.