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)
Job Summary:
Responsible for reviewing medical records, preparing clinical appeals (when appropriate) on medical necessity, length of stay, and authorization denials for hospitalized patients. Utilization Review Manager will be responsible for compliance with CMS Conditions of Participation regarding Utilization Review and Discharge Planning and complies with hospital policies and procedures. Knowledge of criteria for Medicare, Medicaid, HMO and private insurance coverage. The Utilization Review Manager will practice improving quality through coordination of care impacting length of stay, minimizing cost, and ensuring optimum outcomes through
collaboration with CNO, Medical staff, and nursing staff.
Supervisory Responsibility:
None.
Position Qualifications:
Current, valid, and active LPN - Licensed Practical Nurse, BSN - Registered Nurse or LSW- Social Worker license in the state of employment required.
Current BLS certification required
Key Responsibilities / Job Accountabilities:
Additional Skills / Qualifications:
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