RN Utilization Review Coordinator - Hope - Hospital - Okmulgee

MINIMUM QUALIFICATIONS

Education – Incumbent must have Associate Degree in Medical Field, RN Preferred

Experience – Minimum 2 years of experience working with Medicare, Medicaid and Private Insurance.

Licenses & Certification – Possess BLS, CPI (or equivalent certifications required).

Knowledge & Skills –

1. Demonstrates a thorough knowledge of both hospital wide and unit specific policies and procedures, work practices, emergency procedures, and personal protective equipment.
2. Demonstrates ability to maintain composure and professionalism during difficult and high stress situations.
3. Demonstrates ability to interact and communicate with others in a way that promotes a positive and cooperative work environment and ability to channel concerns appropriately.
4. Demonstrates ability and willingness to adjust personal schedule in case of workload fluctuations or other departmental/unit needs.
5. Demonstrates ability to foster sense of teamwork and collaboration within the unit and the hospital.
6. Maintains initiative and enthusiasm in performing job duties.
7. Understands concepts of excellence in customer service and conducts duties in positive, customer-friendly manner to all customers of department, particularly patients, visitors, physicians and other employees.
8. Accepts and supports hospital mission, goals and objectives.
9. Capable of assisting in medical and psychiatric emergencies according to protocol.

JOB SUMMARY

The Utilization Review (UR) has a well-developed knowledge and skills in the areas of medical necessity, and patient status determination.  This individual is responsible for performing a variety of concurrent and retrospective UR related reviews and functions for ensuring that appropriate data is tracked, evaluated and reported.  The UR effectively and efficiently manages a diverse workload in a fast-paced, rapidly changing regulatory environment.  The UR is a member of the UR Committee. 

WORK  ENVIRONMENT

Work is performed in a psychiatric hospital environment.  There is common exposure to contagious disease.  The work may include a certain amount of exposure to hostile and emotionally disturbed patients, families and visitors.  Special attire may be required as protection against infection.

PHYSICAL DEMANDS

Long periods of sitting, standing and walking. Working with patients and supplies requires recurring bending, lifting, squatting, stretching and positioning of patients. Must be able to lift up to 50 pounds.  Must manage stress under many different circumstances. 

ESSENTIAL FUNCTIONS

Satisfactory job performance will be determined by successful execution of the following:

1. Attends team meetings that foster interdepartmental collaboration with the patient and their family as deemed necessary, this includes multidisciplinary meetings and Utilization Review/Treatment Team meetings. Provides input in such meetings regarding utilization review and discharge planning.
2. Provides good liaison relationships with referral sources around the referral, admission, treatment and discharge process.
3. Compiles and analyzes data. Establishes relevant plans, evaluates and reports all to the Director/designee to the quality committee.
4. Knowledgeable of criteria for Medicare, Medicaid, HMO and private insurance coverage.
5. Communicates with physicians to ascertain their plans for a timely discharge.
6. Document UR and discharge planning as an ongoing review.
7. Cooperates with insurance companies, based on information received.
8. Obtains intake referrals, authorizations and prior authorizations (if needed for d/c).
9. Collaborates with nursing, physicians, admissions, fiscal, legal, compliance, coding and billing staff to answer clinical questions r/t medical necessity and patient status.
10. Perform concurrent and retrospective reviews as needed to maintain payment status.
11. Maintains supplies for the unit. Ordering timely to maintain current demands.
12. Promotes and develops positive, professional interaction with peers, senior management and staff through effective written and verbal communication, listening and feedback in times of organizational change.
13. Capable of assisting in medical and psychiatric emergencies according to protocol.
14. Regular attendance and professional attire are required.
15. Performs additional duties as assigned.