Utilization Review Coordinator jobs in Portland, ME
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)
Recently Added Utilization Review Coordinator jobs
Utilization Review Nurse
- Martin's Point Health Care
-
Portland, ME
FULL_TIME
- Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015. Position Summary The Utilization Review Nurse works as a member of a team responsible for ensuring the receipt of high quality, cost efficient medical outcomes for those enrollees with a need for inpatient/ outpatient authorizations. This position receives and reviews prior authorization requests for specific inpatient and outpatient medical services, receives and reviews notification of emergent hospital admissions, completes inpatient concurrent review, establishes discharge plans, coordinates transitions of care to lower/higher levels of care, makes referrals for care management programs, and performs medical necessity reviews for retrospective authorization requests as well as claims disputes. The Utilization Review Nurse will use appropriate governmental policies as well as specified clinical guidelines/ criteria to guide medical necessity reviews and will use effective relationship management, coordination of services, resource management, education, patient advocacy and related interventions to: -Ensure members are receiving appropriate level of care -Promote cost effective medical outcomes -Prevent hospitalization/ readmissions when appropriate -Promote decreased lengths of hospital stays when appropriate -Provide for continuity of care Job Description Key Outcomes/Results: Review prior authorization requests (prior authorization, concurrent review, and retrospective review) for medical necessity referring to Medical Director as needed for additional expertise and review. Utilize evidenced-based criteria, governmental policies, and internal guidelines for medical necessity reviews. Manage the review of medical claims disputes, records, and authorizations for billing, coding, and other compliance or reimbursement related issues Collaborates with other members of the team, the MPHC Medical Directors, healthcare providers, and members to promote effective utilization of resources. This collaboration includes timely communications with in and out of network hospitals, post-acute care facilities, other providers, and internal departments to: authorize services, establish discharge plans, assist to coordinate effective, efficient transitions of care. Coordinates referrals to Care Management, as appropriate. Manages health care within the benefits structures per line of business and performs functions within compliance, contractual and accreditation regulations, e.g. Department of Defense, Centers for Medicaid and Medicare, NCQA, Employer contracts and state insurance regulations, as applicable. Maintains knowledge of applicable regulatory guidelines. Completes all documentation of reviews and decisions, in appropriate systems, according to process/ compliance requirements and within timeliness standards. Participates as a member of an interdisciplinary team in the Health Management Department May be responsible for maintaining a caseload for concurrent cases/ assisting in caseload coverage for the team Acts as a liaison to ensure the member is receiving the appropriate level of care at the appropriate place and time Mentors new staff into case management role as assigned. Assumes extra duties as assigned based on business needs. Participates on committees, work groups, team rounds, and/or projects as designated. Attends on-going training/continuing education, at a minimum annually, to maintain professional competency. Assists in creation and updating of department Policies and Procedures. Participates in quality initiatives and process improvements that reinforce best practice medical management programming and offerings. Education/Experience: Unrestricted state license as a Registered Nurse required; BSN preferred. 3 (total) years clinical nursing experience Utilization management experience in a managed care or hospital environment required Certification in managed care nursing or care management desired (CMCN or CCM) Required License(s) and/or Certification(s): Unrestricted state license as a Registered Nurse Skills/Knowledge/Competencies (Behaviors): Demonstrates an understanding of and alignment with Martin’s Point Values. Maintains current licensure and practices within scope of license for current state of residence. Maintains contemporary knowledge of evidence - based guidelines and applies them consistently and appropriately. Ability to analyze data metrics, outcomes and trends. Excellent interpersonal, verbal and written communication skills Critical thinking: can identify root causes and understands coordination of medical and clinical information Ability to prioritize time and tasks efficiently and effectively Ability to manage multiple demands Ability to function independently Computer proficiency in Microsoft Office products including Word, Excel, and Outlook We are an equal opportunity/affirmative action employer. Do you have a question about careers at Martin’s Point Health Care? Contact us at: jobinquiries@martinspoint.org Martin’s Point Health Care is a progressive, not-for-profit organization providing care and coverage to the people of Maine and beyond. The organization operates six primary care health care centers in Maine and New Hampshire, accepting most major insurance plans. Martin’s Point also administers two health plans: Generations Advantage (Medicare Advantage plans available throughout Maine and New Hampshire), and the US Family Health Plan (TRICARE Prime® plan for active-duty and retired military families in northern New England, upstate New York, and western Pennsylvania). For more information, visit https://careers.martinspoint.org.
- 1 Month Ago
Care Manager (RN) - Utilization Review
- MaineHealth
-
Portland, ME
FULL_TIME
- Summary This is a bargaining unit position Date posted: 01/30/2024 For a limited time MaineHealth is offering up to $10,000 Sign on bonus for all eligible experienced Registered Nurses with 1-3 years ...
- 27 Days Ago
RN Care Manager, Care Coordination, Discharge Planning and Utilization Review
- MaineHealth
-
Biddeford, ME
FULL_TIME
- Summary For a limited time MaineHealth is offering sign on bonuses for Registered Nurses: Registered Nurses with more than 3 years of experience: $20,000 (full time) Eligible candidates are hired into...
- 13 Days Ago
RN Care Manager, Care Coordination, Discharge Planning and Utilization Review - Case Mgmt
- MaineHealth
-
Biddeford, ME
FULL_TIME
- Summary For a limited time MaineHealth is offering sign on bonuses for Registered Nurses: Registered Nurses with more than 3 years of experience: $20,000 (full time) Eligible candidates are hired into...
- 1 Day Ago
Registered Nurse – Authorization Review
- Staffing Solutions Organization LLC (SSO)
-
Augusta, ME
FULL_TIME
- Registered Nurse - Health Services Consultant Authorization Review – Office of MaineCare Services in Augusta, METhis role will be Fulltime and will require 40 work hours per week. Position Duties: Man...
- 16 Days Ago
Registered Nurse - Authorization Review
- Public Consulting Group
-
Augusta, ME
OTHER
- Overview Registered Nurse - Health Services Consultant Authorization Review – Office of MaineCare Services in Augusta, METhis role will be Fulltime and will require 40 work hours per week. This role m...
- 15 Days Ago
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0 Utilization Review Coordinator jobs found in Portland, ME area
Administrative Coordinator
- Martin's Point Health Care
-
Brunswick, ME
- Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to t...
- 4/26/2024 12:00:00 AM
Design Technician
- Wright
-
Portland, ME
- Wright-Pierce, an award-winning, multi-discipline environmental engineering firm specializing in water, wastewater, and ...
- 4/26/2024 12:00:00 AM
Obstetrics and Gynecology Registered Nurse (RN) or Medical Assistant (MA)
- InterMed
-
Portland, ME
- ESSENTIAL FUNCTIONS: Assessment of provider schedules and organize patient flow Assist providers with patient care: Room...
- 4/26/2024 12:00:00 AM
Administrative Coordinator
- ProSearch
-
South Portland, ME
- Are you dynamic, highly organized, proactive administrative professional with a love of all things Maine? Our client, a ...
- 4/25/2024 12:00:00 AM
Clinician - Substance Use Treatment & Recovery Courts
- Maine Health
-
Portland, ME
- Per Diem 165 Lancaster Street Behavioral Health Day/Evening ~ Per Diem / As Need Position ~ Maine state licensure to pra...
- 4/25/2024 12:00:00 AM
Operations Manager
- Floor & Decor
-
Portland, ME
- PURPOSE This position is responsible for all aspects of store operations, which include providing an exceptional shoppin...
- 4/25/2024 12:00:00 AM
Cook
- Northern Light Health
-
Portland, ME
- Northern Light Mercy Hospital Department: Food and Nutrition Services Position is located: Mercy Fore River Work Type: F...
- 4/24/2024 12:00:00 AM
Counter Sales - PORTLAND, ME
- Fisher Auto Parts
-
Portland, ME
- Description **The location of the role is based in PORTLAND, ME (disregard the location listed above) KEY RESPONSIBILITI...
- 4/23/2024 12:00:00 AM
About Portland, Maine
Portland is a city in the U.S. state of Maine, with a population of 67,067 as of 2017. The Greater Portland metropolitan area is home to over half a million people, more than one-third of Maine's total population, making it the most populous metro in northern New England (an area comprising the states of Maine, New Hampshire, and Vermont). Portland is Maine's economic center, with an economy that relies on the service sector and tourism. The Old Port district is known for its 19th-century architecture and nightlife. Marine industry still plays an important role in the city's economy, with an a...
Source: Wikipedia (as of 04/11/2019). Read more from Wikipedia
Income Estimation for Utilization Review Coordinator jobs
$79,739 to $98,777
Portland, Maine area prices
were up 1.6% from a year ago
were up 1.6% from a year ago
What does an Utilization Review Coordinator do?
Utilization Review Coordinator in Fort Lauderdale, FL
Some review coordinator positions require that professionals have training and experience within a more specific field.
January 10, 2020
Utilization Review Coordinator in Asheville, NC
Schick Shadel Hospital is seeking a part-time (20 hours per week) Utilization Review Coordinator (UR Coordinator) to help oversee and perform the process of utilization review to ensure appropriate reimbursement by third party payers.
January 04, 2020
Utilization Review Coordinator in Jacksonville, FL
Excellent benefits, pay, small on-site employee gym, wonderful co-workers and managersFull Review.
January 04, 2020