Utilization Review Technician 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 Technician 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 Technician consults with nurses and physicians as needed. Position is non-RN. May require an associate degree or its equivalent. Typically reports to a supervisor. May require Registered Health Information Technician (RHIT). The Utilization Review Technician gains exposure to some of the complex tasks within the job function. Occasionally directed in several aspects of the work. To be a Utilization Review Technician typically requires 2 to 4 years of related experience. (Copyright 2024 Salary.com)
The Case Manager utilizes the nursing process for age and diagnosis of specific populations to assess, plan and evaluate the care of a designated case load of patients so that clinical and financial outcomes are achieved. Holds primary responsibility for oversight of Care Coordination, Utilization Review and Discharge Planning for all patients, providing direction and delegation as appropriate to accomplish. Responsible for appropriate utilization of medical necessity criteria and provides guidance to medical and other clinical staff in their use.
Primary Duties
Care Coordination:
Directs, coordinates and supervises the care delivered to his/her caseload.
Communicates effectively with patients, families, physicians, staff and other customers.
Contributes to modifications in nurse and physician practice patterns to continuously improve quality of care, patient satisfaction and appropriate use of resources.
Identifies and communicates clinical staff practice variances to the appropriate Director and physician practice variances to the CM/UR Physician Advisor.
Utilization Review:
Maximizes positive financial outcomes for his/her designated case types.
Performs and/or delegates admission and continued stay review for all payers and levels of care; performs these responsibilities within 24 hours of admission and continued stay reviews not less than every three (3) days.
Utilizes consistent processes to assure that all patients are evaluated and monitored for appropriate resource consumption.
Participates in the Case Management/Utilization Review Committee formal processes.
Qualifications/Specifications:
Key Relationships
Initiative
Professionalism
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