Utilization Review Program Coordinator RN
About The Position
The Utilization Review Nurse Coordinator is accountable for oversight of the Utilization Management (U.M.) program at Valley Children's Healthcare, under the direction of department leadership. Under minimal supervision, the UR Nurse Coordinator reviews and screens the appropriateness of services, the utilization of hospital resources and the quality of patient care rendered. The position combines clinical, business and regulatory knowledge and skill to reduce significant financial risk and exposure caused by concurrent and retrospective denial of payments for services provided. Through continuous assessments, problem identification and education, the coordinator will facilitate the quality of health care delivery in the most cost effective manner. The coordinator will ensure compliance with all regulations related to Utilization Management, will develop quarterly reports for the U.M. Medical Director for presentation at Pharmacy Therapeutics & Utilization (PT&U) committee, and will facilitate UM subcommittee meetings.
Requirements
- College Degree - 2 year Nursing (required)
- RN - Reg Nurse (required)
- Minimum five (5) years Full time equivalent RN experience in an acute care hospital. (required)
- Computer Skills
- Knowledge of UM regulations.
- Knowledge of private and public payer reimbursement practices and procedures.
- Excellent organizational and communication skills and ability to work with a variety of health care professionals.
- Ability to work independently.
- Computer Skills Proficiency with word processing, spreadsheets and database software.
- To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.
Nice To Haves
- College Degree - 4 year Nursing or related field (preferred)
- Pediatric experience and experience in Case Management and/or Utilization Review. (preferred)
Responsibilities
- Reviews and screens the appropriateness of services, the utilization of hospital resources and the quality of patient care rendered.
- Reduce significant financial risk and exposure caused by concurrent and retrospective denial of payments for services provided.
- Facilitate the quality of health care delivery in the most cost effective manner through continuous assessments, problem identification and education
- Ensure compliance with all regulations related to Utilization Management
- Develop quarterly reports for the U.M. Medical Director for presentation at Pharmacy Therapeutics & Utilization (PT&U) committee
- Facilitate UM subcommittee meetings.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
