UTILIZATION REVIEW COORDINATOR/ PRN - DAYS (M- F)

UHS•Raleigh, NC

About The Position

The Utilization Review Coordinator coordinates and monitors the appropriate utilization and documentation of services for patients in inpatient and outpatient programs, and coordinates authorizations with third-party payors. The role reviews cases for admission and continued-stay appropriateness and discharge planning, and supports high-quality patient care by analyzing, reviewing, and evaluating clinical practices. It maintains communication about treatment through documentation and verbal exchange and works with internal and external entities to facilitate access to resources. The position is PRN, with a Monday-to-Friday schedule. Responsibilities include conducting concurrent and extended-stay reviews, preparing and submitting appeals to third-party payors, sending discharge information to insurers within 24 hours of discharge, maintaining utilization review records, communicating payor issues and insurance information to the care team, attending daily treatment team meetings, gathering review information from patient records and team members, and performing internal utilization reviews. The coordinator must also identify, document, and report suspected adult or child abuse and neglect to appropriate parties.

Requirements

Bachelor's degree in Nursing, Counseling, Psychology, or Social Work.
One year of Utilization Management experience in a hospital setting.
Knowledge of behavioral managed care and clinical assessment skills to align patient acuity with level-of-care practice guidelines.
RN licensure or a master's degree in a behavioral health field such as Counseling, Psychology, or Social Work.
Skills in applying DSM methodology.
Excellent telephone etiquette, tact, audible speech, and enunciation.
Ability to interact effectively with people in diverse roles, backgrounds, cultures, and socioeconomic classes.
Effective oral and written communication skills and ability to analyze and evaluate information.
Ability to concentrate on tasks and meet deadlines.
Intermediate computer skills.
Organizational, time-management, problem-solving, and crisis-management skills; flexibility, creativity, and ability to manage stress.
Understanding of clinical assessment, diagnoses, and interventions with patients.
Understanding of admission and discharge criteria and functions.
Understanding of medical terminology, diagnostic terms, treatment modalities, and medical record keeping.
Understanding of psychiatric evaluations, medical consultations, lab results, medication management, and other components of patient treatment.

Nice To Haves

Master's degree.
Experience in an inpatient psychiatric setting as a counselor and/or nurse.

Responsibilities

Coordinate and monitor appropriate utilization and documentation of services throughout treatment for patients in inpatient and outpatient programs.
Coordinate authorization with third-party payors.
Review cases for appropriateness of admission, continued stay, and discharge planning.
Support high-quality patient care through analysis, review, and evaluation of clinical practices within the hospital.
Maintain communication regarding treatment through documentation and verbal exchange.
Communicate with internal and external entities to facilitate acquisition of resources.
Conduct concurrent and extended-stay reviews on the appropriate day or at the specified time.
Prepare and submit appeals to third-party payors, coordinating pertinent data to support the hospital and patient.
Call or fax discharge information to insurance companies within 24 hours of discharge.
Maintain and update review logs and other Utilization Review department records.
Communicate pertinent third-party payor issues to the doctor and treatment team.
Attend daily treatment team meetings to discuss acuity issues, payor needs, and information for reviews.
Gather review information independently from patient records and seek information from treatment team members as needed.
Explain insurance information, benefits, and available levels of care to team members.
Perform internal utilization reviews as indicated.
Identify, document, and report instances of adult or child abuse and neglect to appropriate parties, including management, police, and state agencies.