Clinical Utilization Review Coordinator

Job Title:Clinical Utilization Review Coordinator

Department:Nursing

Reports To:Chief Nursing Officer

Clinical Utilization Review Coordinator

Position Summary:The Clinical Utilization Review Coordinator is responsible for evaluating the medical necessity, appropriateness, and efficient use of hospital resources for inpatient, observation, outpatient treatment room, outpatient surgery, and other applicable services. Responsibilities include utilization review, prior authorizations, care coordination and discharge planning, quality data abstraction, and assisting with scheduling and Swing Bed Coordination as needed.

The Coordinator collaborates with physicians, hospital departments, payers, and external review agencies to support appropriate levels of care, regulatory and payer compliance, effective transitions of care, quality patient outcomes, and appropriate reimbursement. The position monitors utilization trends, identifies opportunities for improvement, and provides data, reports, and recommendations to support efficient resource utilization, quality improvement, and patient safety.

Summary:Reviews of the utilization of hospital resources against established criteria documentation requirements of external agencies. Monitors and evaluates necessity, appropriateness, and efficient use of health care services. Provides reports and recommendations to medical and hospital staff for improved utilization of resources and to maximize reimbursement while maintaining quality care.

Essential Duties and Responsibilities

The following duties and responsibilities are considered essential to the position. Other duties may be assigned.

• Performs utilization reviews for inpatient, observation, outpatient treatment room, outpatient surgery, and other applicable services to assess medical necessity, admission status, level of care, and continued-stay appropriateness using established criteria and payer requirements.
• Reviews clinical documentation for compliance with regulatory and payer requirements; identifies cases not meeting established criteria and coordinates referrals to the physician advisor or designated medical staff for further review.
• Coordinates and obtains prior authorizations for applicable services and communicates with payers and external review agencies regarding authorizations, medical necessity, level of care, continued stays, and denials.
• Coordinates and assists with discharge planning, care coordination, and transitions of care in collaboration with physicians, nursing, Social Services, Case Management, and other departments to support appropriate, timely, and effective patient care.
• Assists with Swing Bed Coordination and serves as backup Swing Bed Coordinator in their absence.
• Assists with scheduling services, procedures, or appointments as needed to support patient care and departmental operations.
• Performs quality data abstraction in collaboration with the Director of Quality and Risk Management; identifies and reports quality, infection prevention, patient safety, risk management, and other concerns identified through record reviews.
• Compiles and analyzes utilization data, authorization outcomes, denials, trends, and other required reports; provides recommendations to support appropriate resource utilization, reimbursement, documentation, and quality improvement.
• Collaborates with the physician advisor, medical staff, Business Office, Patient Registration, and other internal and external stakeholders to address utilization concerns, documentation needs, payer requirements, and opportunities for improvement.
• Provides education to hospital employees and medical staff regarding utilization review processes, medical necessity criteria, prior authorization requirements, documentation standards, and applicable regulatory or payer changes.
• Maintains current knowledge of utilization management standards, Medicare regulations, payer policies, applicable review criteria, DRG methodology, ICD-10 coding, and other relevant requirements.
• Maintains patient confidentiality and complies with applicable privacy, security, regulatory, and organizational requirements.
• Demonstrates professional conduct, effective communication, dependable attendance, and cooperation with patients, families, physicians, coworkers, payers, and external agencies.
• Maintains professional growth through continuing education and training.
• Performs other duties as assigned.

Essential Duties and Responsibilities:include the following. Other duties may be assigned.

• Performs reviews of inpatient medical records to determine admission level of care and continued stay appropriateness.
• Coordinates with other hospital departments such as social services, business office, and patient registration in matters of review decisions, discharge planning, and fiscal communications.
• Appropriately reports quality, infection control, and risk issues found during record reviews.
• Coordinates closely with the physician advisor, referring cases that do not meet criteria and determining corrective action plan on utilization problems.
• Acts as the hospital liaison with Medicare, commercial payers, and other external review agencies.
• Compiles and analyzes data for utilization management activities. Maintains logs and statistics.
• Provides education to hospital and medical staff regarding utilization management.
• Maintains professional growth and development. Keeps current on utilization rules, regulations, and policies.
• Show up for work as scheduled and able to get along with others.

Qualifications

Qualifications:To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience:                                           

Current RN or LPN license in the state of Kansas and graduation from an approved nursing program. Three years of clinical nursing experience, with one year of medical/surgical nursing experience preferred. Utilization review experience desired. Knowledge of DRG and ICD-10 coding, ISD-A criteria, and Medicare regulations preferred.

 Language Skills:                                                    

Ability to read and comprehend simple instructions, short correspondence, and memos.  Ability to write simple correspondence.  Ability to effectively present information and address questions from residents, family members, medical staff, other employees, and the public.

Mathematical Skills:                                              

Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals.  Ability to compute rate, ratio, and percent.

Reasoning Ability:

Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form.  Ability to deal with problems involving a few concrete variables in standardized situations.

Certificates, Licenses, Registrations:

      Registered Nurse licensed in State of Kansas

      Current CPR certification.

Physical Demands:The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to stand; walk; use hands to feel; reach with hands and arms; stoop, kneel, crouch, or crawl and talk or hear. The employee is regularly required to sit. The employee must regularly lift on an occasional basis a maximum of 50 pounds with frequent or constant lifting of 25 pounds.  Specific vision abilities required by this job include close vision, distance vision, color vision, depth perception and ability to adjust focus.