Employment Type:

Shift:

Description:

POSITION PURPOSEThe Utilization Review (UR) Coordinator I colleague is responsible for conducting the utilization review process in accordance with federal and state law, licensure/ accreditation and hospital standards and Third-Party payor requirements.  The review process includes but is not limited to admission/re-admission review (includes identification of fragmentation of care, combined admissions), pre-certification/re-certification review, data gathering for identified projects, internal audits, retrospective reviews, statistics, coding, billing or verification issues.  

• ESSENTIAL FUNCTIONS AND RESPONSIBILITIES MAY INCLUDE
• 1.    
• Provides leadership and expertise for utilization management processes.
• 2.    
• Completes the UR review and obtains authorization on retrospective cases that the insurance has changed after discharge by performing the following:
• o    
• Reviews assigned medical records in a timely manner for admission, concurrent or retrospective review using criteria to determine appropriate level of care.
• o    
• Exhibits consistent documentation of criteria in the EMR
• o    
• Follows the hospital Utilization Review Plan to ensure effective and efficient use of hospital services.
• o    
• Demonstrates competency with InterQual application with a passing score on competency test, Inter Rater Reliability when administered.   Demonstrates competency using MCG criteria. 
• o    
• Analyzes and disseminates appropriate clinical information for payer authorization. Extracts pertinent information and communicates in a succinct fashion to the 3rd party payer. Demonstrates sound clinical judgement that supports IP level of care for appropriate reimbursement to the hospital.  The UR Coordinator must be knowledgeable of health plan contracts and meet their clinical submission deadlines.
• o    
• Demonstrates expertise in providing IS/SI criteria to Third Party Payers to obtain authorization for level of care and/or procedures for initial admission, concurrent or retrospective reimbursement.
• o    
• Contacts the internal physician advisor on cases that do not meet established guidelines for admission or continued stay
• o    
• In the event of an inpatient denial by the payer, obtains further documentation from the physician to support an IP level of care.
• 3.    
• In the event of an inpatient denial by the payer, obtains further documentation from the physician to support an IP level of care.
• 4.    
• Provides leadership and expertise for utilization management processes.
• 5.    
• Manages the DNFB (discharged but not final billed) list and other UR hold reports to ensure
• o    
• Account problems are being resolved and clean claims released timely
• o    
• Authorization is secured timely
• o    
• Claims can be released for hospital reimbursement
• 6.    
• Develops and shares reports as requested.
• 7.    
• Initiates and coordinates Peer-to-Peer discussions with physician and payer as warranted.
• 8.    
• Obtains authorizations as required for reimbursement from appropriate Third-Party Payor.
• 9.    
• Mediates and coordinates process between insurance company and hospital clinical staff when a patient requires transfer to another acute care hospital.
• 10.    
• Processes all technical and administrative denials for all clinical areas of the hospital and facilitates the appeal process as appropriate.
• 11.    
• Communicates to the payer patient discharge date and discharge plan. 
• 12.    
• Mediates between case manager and payer to ensure a seamless transition in care and appropriate post-acute follow-up.
• 13.    
• Provides updated third-party payor information to assigned Case Manager for continuity of care.
• 14.    
• Identifies areas of quality concerns, inappropriate use of resources and any other issues that restrict the implementation of hospital, department objectives and refers findings for appropriate follow-up.
• 15.    
• Reviews IP denials with the appeals nurse to determine appropriate status and reimbursement from payer. Appeal determinations are made at that time.
• 16.    
• Assists other departments in the reimbursement process including, but not limited to, changes in inpatient, outpatient and observation status, identification of appropriate surgical status and other interventions needed to reduce patient and hospital liability of financial loss.
• 17.    
• Demonstrates proficiency in using various computer programs required including EPIC and various payer portals, etc.
• 18.    
• Responsible for combining admissions on those cases that are appropriate and communicating to Insurance Verification and Health Information Management.
• 19.    
• Assists with payer-specific audits as assigned, i.e. RAC, HDI
• 20.    
• Functions as a resource to physician, hospital staff or departments and other ‘customers” of the hospital to assist in complying with the utilization review processes.
• 21.    
• Participates in UR Committee, department staff meetings and ad hoc committees on an as needed basis.
• 22.    
• Participates in review and analysis of outcome data related to UR functions and identification of system and process issues that contribute to denials.
• 23.    
• Discusses patient and hospital information only among appropriate personnel in appropriate private places. 
• 24.    
• Maintains good rapport and cooperative relationships, and approaches conflict in a constructive manner. 
• 25.    
• Helps to identify problems, offer solutions, and participate in their resolution. 
• 26.    
• Maintains the confidentiality of information acquired pertaining to patients, physicians, associates, and visitors to Trinity Health. 
• 27.    
• Behaves in accordance with the Mission, Vision and Values of Trinity Health. 
• 28.    
• Assumes responsibility for performance of job duties in the safest possible manner, to assure personal safety and that of coworkers, and to report all preventable hazards and unsafe practices immediately to management.

  OTHER FUNCTIONS AND RESPONSIBILITIES 

  Performs other duties as assigned.

  REQUIRED EDUCATION, EXPERIENCE AND CERTIFICATION/LICENSUREEducation: Associate’s degree in health-related field or nursing preferred.

  Experience: Three years of recent acute care utilization management experience. 

  Licensure/Certification:  Current RHIT or LPN preferred

• REQUIRED SKILLS AND ABILITIES
• 1.    
• Understanding of computers and software in order to collect and report information for required data sources.
• 2.    
• Ability to work autonomously with little direction and be accountable for outcomes.
• 3.    
• Excellent customer service orientation skills necessary to deal effectively with various levels of hospital personnel, outside customers and community groups.
• 1.    
• Assists with the development of workflow, policies, and procedures to optimize ECT services, ensuring efficiency and effective service delivery.
• 2.    
• Develop training for staff to provide high-quality service delivery between internal and external resources.
• 3.    
• Works closely with both internal programs/services and external organizations to coordinate patient referrals, ensuring seamless integration of services.
• 4.    
• Coordinates all pre-procedure requirements and obtains documentation to ensure clearance of procedure.
• 5.    
• Manages the ECT scheduling and throughput of services including minimizing unfilled time.
• 6.    
• Coordinates services with other departments to ensure safe flow of service delivery.
• 7.    
• Coordinates prior authorization, benefits verification, and ensures reduction of denials.
• 8.    
• Partner with billing to review coding/claims issues.
• 9.    
• Assures complete, accurate, and timely documentation of clinical information in the EHR, incorporating current documentation and billing guidelines and requirements.
• 10.    
• Onboarding new colleagues to ECT workflows; provide training and education to current colleagues as needed.
• 11.    
• Track and report out all Key Performance Indicators (KPI) timely including time-to-start, cancelations/no-show rates, adverse events, Length of Stay (LOS), recidivism, and utilization.
• 12.    
• Prepare for surveys/audits, as needed.
• 13.    
• Maintains good rapport and cooperative relationships. Approaches conflicts in a constructive manner. Helps to identify problems, offer solutions, and participate in their resolution. 
• 14.    
• Maintains the confidentiality of information acquired pertaining to patient, physicians, associates, and visitors to Trinity Health. Discusses patient and hospital information only among appropriate personnel in appropriate private places. 
• 15.    
• Behaves in accordance with the Mission, Vision and Values of Trinity Health. 
• 16.    
• Assumes responsibility for performance of job duties in the safest possible manner, to assure personal safety and that of coworkers, and to report all preventable hazards and unsafe practices immediately to management.

  REQUIRED EDUCATION, EXPERIENCE, AND CERTIFICATION/LICENSUREEducation: Master’s degree in social work, counseling, bachelor’s-level RN, and/or equivalent license.

  Experience: 3+ year in behavioral health, preoperative services, care coordination, or related setting.

  REQUIRED SKILLS AND ABILITIES1.    Prior experience with Utilization Review2.    Experience with ECT or other procedural coordination of care preferred.

  Our Commitment

  Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.