Full-time Utilization Review Coordinator

Lexington Regional Health Center•Lexington, NE

5d•Onsite

About The Position

Lexington Regional Health Center is seeking a full-time Utilization Review Coordinator to join their Nursing Department. This non-exempt position plays a crucial role in coordinating patient care, discharge planning, and ensuring safe transitions from the hospital to home. The coordinator will work collaboratively with a multidisciplinary team, including providers, nursing staff, community resources, and patients, to optimize patient outcomes and reduce readmissions. Responsibilities include data collection, chart reviews, and participation in various meetings and committees related to utilization review and discharge planning. The role requires strong critical thinking, communication, and organizational skills, as well as proficiency in electronic medical records and other relevant software.

Requirements

Knowledge and understanding of utilization review processes, medical necessity criteria, level-of-care determinations, and payer authorization requirements.
Ability to review clinical documentation and apply established criteria, such as InterQual or other organization-approved guidelines, to support appropriate admission status, continued stay, and discharge planning decisions.
Minimum of two years acute care, case management, utilization review, discharge planning, or care coordination experience preferred.
BLS certification required within six months of hire and/or orientation.
Knowledge of Medicare, Medicaid, commercial payer, and workers’ compensation authorization processes, including notification requirements, concurrent review, clinical documentation submission, and denial prevention practices.
Ability to maintain accurate, timely, and complete documentation in the electronic medical record and other required utilization review tracking systems.
Ability to maintain strict confidentiality and comply with HIPAA, organizational privacy standards, and all requirements related to protected health information.
Strong critical thinking, analytical, organizational, and problem-solving skills with the ability to prioritize multiple reviews, deadlines, and communication needs.
Ability to communicate professionally and effectively with providers, nursing staff, patients, families, insurance companies, workers’ compensation representatives, regulatory agencies, and members of the interdisciplinary care team.
Ability to complete reports, correspondence, clinical summaries, committee materials, and audit documentation at a professional level.
Ability to respond appropriately to inquiries, concerns, and complaints from patients, employees, payers, providers, and regulatory agencies.
Ability to effectively communicate and collaborate with individuals from diverse backgrounds while demonstrating professionalism, respect, and patient-centered advocacy.
Computer proficiency required, including use of electronic medical records, Microsoft Office applications, payer portals, and other software systems used for utilization review and care coordination.
Successful completion of required training related to standard precautions, transmission-based precautions, infection prevention, patient safety, and other competency requirements applicable to the position.

Nice To Haves

Minimum of two years acute care, case management, utilization review, discharge planning, or care coordination experience.

Responsibilities

Coordinates the care and discharge planning of hospitalized patients from a multi-disciplinary standpoint.
Participates in multi-disciplinary rounding to include: provider rounds, daily huddle, weekly discharge planning meeting, etc.
Assists in coordinating patient discharges by ensuring health education management is provided to patients and their support systems, regarding post hospital care and may coordinate needed resources when applicable.
Works to provide safe transitions from the hospital to home while ensuring patient safety, patient understanding of their care plan and future plans, along with reducing readmissions.
Works collaboratively with all aspects of patient care team to include various healthcare professionals, hospital departments, community resources and the patient.
Coordinates and collects quality data including call backs, swing-bed and Utilization Review.
Assists with goals to reduce readmissions, over utilization of Emergency Room through chart reviews, process improvements and etc. Such as contacting patients after dismissal to ensure that the plan of care was understood and followed. (Medication reconciliation, future appointments are made and any patient questions are answered.)
Attends and participates in the organization's Utilization Review Committee.
Helps assist patients and designated support system on preventive measures, disease management, health care management throughout the health system, etc.
Manages and intakes swing bed referrals. Communicates with multidisciplinary team to ensure patient centered holistic care and develop a multidisciplinary plan of care through IDT meetings. Ensures documenting of certification of stay and recertifications. Complies with all swing-bed rules and regulations. May assist with swing-bed chart reviews.
Maintains medical record documentation to accurately reflect care administered and patient's condition. Records all care information concisely, accurately and completely in a timely manner in the appropriate format and on the appropriate forms.
Provides holistic support to patients and patient designated support system.
Assures medical criteria is met for admission to appropriate service by discussion with providers and reviewing documentation.
Assists in Chart Review Audits for Utilization Review Committee.
Rotating for UR call to ensure appropriate UR coverage on weekends.
Participates in patient care activities that could include blood exposure and risk to bloodborne pathogens (e.g., lacerations, handling of blood-contaminated specimens, etc.).
Responsible for safe bagging and disposal of biohazardous waste.
Responsible for following safe-injection practices.
Responsible for ensuring the environment meets appropriate governing body standards.
Ensures patients and visitors follow current infection control guidelines.
Responsible for proper collection, storage and labeling of biological specimens.
Maintains patient and staff safety through the use of patient safety tools (TeamSTEPPS, Just Culture, etc.).
Communicates all departmental concerns with the Director of Care Management and Social Services/or Chief Nursing Officer.
Regular attendance at the assigned work location is required.
Performs all other duties as assigned.