Utilization Review Coordinator jobs in Maine
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.
- 28 Days 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 ...
- 20 Days Ago
Social Worker DCP-Utilization Review
- Pen Bay Medical Center
-
Rockport, ME
FULL_TIME
- Position Summary Assesses psychosocial needs of patients. Provides individual and family education and counseling. As part of a multidisciplinary team, identifies issues that can pose a barrier to a s...
- 24 Days Ago
Social Worker DCP-Utilization Review
- MaineHealth
-
Rockport, ME
FULL_TIME
- Summary Position Summary Assesses psychosocial needs of patients. Provides individual and family education and counseling. As part of a multidisciplinary team, identifies issues that can pose a barrie...
- 1 Month Ago
Registered Nurse (RN) Care Manager - Utilization Review
- Waldo County General Hospital
-
Belfast, ME
FULL_TIME
- For a limited time MaineHealth is offering up to a $10,000 Sign on bonus for all eligible experienced Registered Nurses with 0-3 years of experience and $20,000 for experienced Registered Nurses with ...
- 9 Days Ago
Registered Nurse (RN) Care Manager - Utilization Review
- MaineHealth
-
Belfast, ME
FULL_TIME
- Summary For a limited time MaineHealth is offering up to a $10,000 Sign on bonus for all eligible experienced Registered Nurses with 0-3 years of experience and $20,000 for experienced Registered Nurs...
- 8 Days Ago
Utilization Review Coordinator jobs at Popular Companies
Utilization Review Coordinator (Remote Position)
- BayMark Health Services
-
Deerfield Beach, FL
- Description Position at BayMark Health Services Residential - Utilization Review Coordinator Role and Responsibilities M...
- 4/18/2024 12:00:00 AM
Utility Coordinator
- Ces Group Engineers Llp
-
Charlotte, NC
- CES is looking for a ambitious, passionate, Utility Coordinator to join our relationship inspired, regionally recognized...
- 4/18/2024 12:00:00 AM
Utilities Coordinator
- Rad Diversified
-
Exton, PA
- Job Description Job Description RAD Diversified is a GREAT place to work! Here’ s what we offer: Comprehensive Healthcar...
- 4/17/2024 12:00:00 AM
Utility Supervisor
- Transdev Inc.
-
Fairfax, VA
- Utility Supervisor Job Description OVERVIEW: The Utility Supervisor reports directly to the Maintenance Manager in fulfi...
- 4/17/2024 12:00:00 AM
Utilization Review Coordinator
- TheraMatrix
-
Pontiac, MI
- Job Description Job Description Duties and Responsibilities: Initial authorizations of outpatient physical therapy servi...
- 4/16/2024 12:00:00 AM
Utility Coordinators
- Telforce Group Llp
-
Daytona Beach, FL
- Telforce Group is looking for Utility Coordinators These are Direct Hire Positions Work is in Daytona & Melbourne, FL Ov...
- 4/16/2024 12:00:00 AM
Utility Coordinator
- The Rios Group Inc.
-
Universal City, TX
- Job Summary The Utility Coordinator will coordinate all facets of utility issues relating to assigned roadway projects w...
- 4/16/2024 12:00:00 AM
Utilization Review Coordinator / Case Management / PRN
- Christus Health
-
Santa fe, NM
- Description POSITION SUMMARY: Registered Nurse uses approved screening criteria (MCG®/CMS Inpatient List) to determine t...
- 4/14/2024 12:00:00 AM
About Maine
To the south and east is the Atlantic Ocean and to the north and northeast is New Brunswick, a province of Canada. The Canadian province of Quebec is to the northwest. Maine is both the northernmost state in New England and the largest, accounting for almost half of the region's entire land area. Maine is the only state in the continental US to border only one other American state (New Hampshire to the South and West).
Maine is the easternmost state in the United States in both its extreme points and its geographic center. The town of Lubec is the easternmost organized settlement in the United...
Source: Wikipedia (as of 04/11/2019). Read more from Wikipedia
Income Estimation for Utilization Review Coordinator jobs
$78,449 to $97,179
Most Popular Cities in Maine for Utilization Review Coordinator Jobs
What does an Utilization Review Coordinator do?
Utilization Review Coordinator in Long Beach, CA
The Utilization Review Coordinator contributes to moderately complex aspects of a project.
January 05, 2020
Utilization Review Coordinator in Gary, IN
Candidates for this role must have a good understanding of medical terminologies, and stay tuned with latest developments in the field; they should possess knowledge of reviews such as MAC, KEPRO, and RAC; strong observing skills and the ability to monitor safety plans are also needed.
December 29, 2019
Utilization Review Coordinator in Chicago, IL
Including requirements, responsibilities, statistics, industries, similar jobs and job openings for Utilization Review Coordinator.
December 30, 2019