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)
Education: Must have a Bachelors degree; Masters degree or RN license preferred.
Assure residents meet criteria for admission, and review initial clinical information through discharge.
Monitor and manage client/patient/resident’s cases through development and implementation of individual care plans, collecting clinical data and remain informed by continuous review of documentation.
Coordinate care by tracking, monitoring, and reporting on inpatient or outpatient care.
Manage client/patient/resident’s cases with knowledge and expertise with the patient population of the facility.
Convey medical criteria and clinical information between the client/patient/residents’ insurance provider and treatment team as warranted and may also provide this information to the business office, as needed.
Conduct precertification with third party payers and negotiate approved days with the provider for the patient/resident admission.
Assigned tasks for admission review, concurrent review and participate in discharge planning.
Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities
The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c)
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