Utilization Management Coordinator

Description The Utilization Review Coordinator assists in the operations of the Utilization Review Department and ensures compliance with patient care quality standards. Coordinates activities in the process of evaluating the use of professional medical care, services, procedures and facilities using pre-established criteria; performs admission and concurrent review of all patients using pre-established criteria. Interfaces with other departments, mental health professionals and external review agencies; appeals adverse decisions by external review agencies.

JOB RESPONSIBLITIES:

1. Coordinate the integration of the Utilization Review Department’s functions with other aspects of overall patient care.
2. Ensures compliance with patient care and medical practice standards.
3. Participates in the development/revision, implementation and communication of goals, policies, guidelines and standards for the Utilization Review Department in accordance with the facility’s policies and objectives, and JCAHO, CMS and licensing standards.
4. Monitors admission and concurrent reviews of all patients, both internally and externally, as outlined in the Utilization Review Plan.
5. Functions as hospital intermediary with external review agencies.
6. Ensures that appropriate parties are notified in the event of an admission, or continuing stay denial.
7. Manages utilization review data and information flow.
8. Serves as administrative staff member to the Utilization Review/Medical Records Committee.
9. Participates in the educational process for the medical staff.
10. Collaborates with hospital personnel and medical staff to ensure optimal patient care.
11. Promotes a positive working environment and guest relations.
12. Assumes and/or performs additional duties as requested.

 
Candidates must provide salary requirements to be considered

Requirements EDUCATION/EXPERIENCE:

Must be a graduate of an accredited Nursing or Social Work education program. MSN or MSW preferred; or equivalent experience. Prefer 5 years clinical experience with a psychiatric mental health population. Licensure and registration by the Colorado Dept. of Registration as an RN or licensed Social Worker preferred. Possess knowledge of Utilization Review, insurance and managed care procedures related to a health care environment. Current knowledge of regulating/accrediting agency guidelines. Basic computer proficiency and knowledge of statistical analysis required.

 
GENERAL WORKING ENVIRONMENT: Working conditions for all employees are as follows, but not limited to a psychiatric hospital setting; some risk involved in the event of aggressive patient(s); work load may include day, evening, night, weekend and/or holiday shifts. The Coordinator of Utilization Review is occasionally exposed to fumes or airborne particles, toxic or caustic chemicals, blood borne pathogens, risk of electric shock, and loud noise levels.

Mental demands described herein are representative of those which must be met by an employee to successfully perform the essential functions of the job, but are not limited to the ability to remain calm in a stressful environment; and the emotional stability, physical stamina and agility to handle stress and respond quickly and effectively to emergency situations.