Utilization Review Coordinator conducts utilization reviews to determine if patients are receiving care appropriate to illness or condition. Monitors patient charts and records to evaluate care concurrent with the patients treatment. Being a Utilization Review Coordinator reviews treatment plans and status of approvals from insurers. Collects and complies data as required and according to applicable policies and regulations. Additionally, Utilization Review Coordinator consults with physicians as needed. May require a bachelor's degree. Typically reports to a supervisor. Typically requires Registered Nurse(RN). The Utilization Review Coordinator contributes to moderately complex aspects of a project. Work is generally independent and collaborative in nature. To be a Utilization Review Coordinator typically requires 4 to 7 years of related experience. (Copyright 2024 Salary.com)
When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.
Job Type:
RegularScheduled Hours:
20Work Shift:
Day (United States of America)Position Summary: Reporting directly to the Chief Medical Officer (CMO), the Physician Advisor will play an active role in optimizing healthcare resource utilization, ensuring quality, patient care, and managing valuable organizational resources. The role will involve collaborating with key stakeholders of multidisciplinary teams-Nursing staff leadership, hospitalist and closely collaborates with the director of care transitions to assess and guide the appropriate utilization of medical services while maintaining compliance with all regulatory requirements.Job Description:
Purpose:
Provide leadership and expertise relative to the level of care management, concurrent and retro commercial payer validation of medical necessity recommendations, as requested
Policy Setting Responsibilities
Responsible for utilization review and medical necessity recommendations, as requested
Decision-Making Authority:
Responsible for collaborating with the utilization review department as these issues relate to commercial payers, to meet established goals and for leading physician participation and compliance with responsibilities.
Supervisory Responsibility:
Responsible for engaging physicians in utilization review and medical necessity activities
Key responsibilities:
Utilization review and inpatient clinical optimization: (include all utilization review, patient status, observation, escalation, second level and peer to peer reviews.
- Conduct thorough medical review of patient cases to determine the medical necessity of services provided.
- Assess the appropriateness of treatment plans and interventions in accordance with clinical guidelines and best practice
- Collaborate with care teams to optimize, patient care, pathways, reduce unnecessary services, and promote efficient resource allocation
- Serves as physician expert and provide support to utilization review team regarding utilization decisions pertaining to commercial payors including screening for appropriateness of hospitalization, peer –to-peer discussions with payor provider representatives, participation in the observation escalation process, clinical reviews of utilization review activities.
FLSA Status:
ExemptClear All
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