Utilization Review Coordinator - Full Time, Days (Hybrid-Bellflower)

Position Summary

The Utilization Review Coordinator oversees the completion of all admission and concurrent reviews of all MediCal patients. Completes MediCal Treatment Authorization Requests (TAR) for the Organization. Uses “level of care” criteria to determine appropriateness of admission and extended duration reviews. Communicates with a variety of clinical disciplines and Physician Advisor to clarify and enforce criteria.

Required Qualifications

• Licensed LVN or RN in the State of California
• 2 years previous Case Management experience
• Must demonstrate customer service skills appropriate to the job
• Computer literacy and proficiency
• Excellent written and verbal communication skills
• Ability to establish and maintain effective working relationships within the organization
• Ability to multitask and maintain a work pace appropriate to workload
• 2 years of clinical experience

Preferred Qualifications

• Certified Case Manager (CCM)
• Prior experience with Department of Health Services

Physical Requirements

These are requirements normally expected to perform regular job duties. Reasonable accommodations may be made in compliance with the Americans with Disabilities Act of 1990, and applicable, state and local law, to enable individuals with disabilities to perform the essential functions. Incumbent must be able to successfully perform all of the essential functions of the job with or without reasonable accommodation.

• Standing - Frequently
• Walking - Frequently
• Sitting - Frequently
• Reaching with Hands and Arms - Occasionally
• Climb or Balance - Occasionally
• Stooping, Kneeling, Crouching, or Crawling - Occasionally
• Talking - Constantly
• Hearing - Constantly
• Seeing - Constantly
• Performing repetitive motions with arms or hands - Occasionally
• Lifting, carrying, pushing or pulling up to 10 lbs - Occasionally
• Lifting, carrying, pushing or pulling up to 25 lbs - Occasionally
• Lifting, carrying, pushing or pulling up to 50 lbs - Occasionally
• Lifting, carrying, pushing, or pulling greater than 50 lbs - None
• Driving - Occasionally

The essential functions below are not intended to be an exhaustive list of all duties that may be assigned to this position, nor does it restrict the duties which may be assigned to this position if such duties reasonably relate to the position.

• Writes timely and accurate Treatment Authorization Requests (TAR), including requests for extension of stay in hospital and retroactive MediCal extensions. Ensures that TAR includes all necessary information, including a signed admission order by the admitting physician.
• Coordinates admissions and concurrent reviews of MediCal patients. Applies utilization review criteria to determine appropriate level of care and length of stay. Ensures utilization review is completed and documented concurrently, and provided to patient’s payer as required.
• Acts as an effective liaison to medical staff to ensure continuity of care in accordance with the patients plan of care. Refers both admission and continued stays, where criteria have not been met to physician advisor. Maintains liaison with the Medical Staff, Admitting, Business Office, Medical Records, Nursing and Administration
• Actively participates in patient rounds on a daily. Communicates any required follow up through Case Management progress notes.
• Educates Medical Staff, Clinical Staff, and Case Management on CMS/MediCal requirements and regulations, including 1x1 with physicians (case specific), NEO – new staff, CM leadership team on a quarterly basis, and ancillary departments.

Pay Rate: Min - $32.70 l Max - $47.20

Job Listing ID: 1781829