Utilization Review Coordinator

The Utilization Review Coordinator is responsible for management of all utilization review and case management activities for the facility’s inpatient, partial hospitalization, and outpatient programs.  Conducts concurrent reviews of all medical records to ensure criteria for admission and continued stay are met and documented, and to ensure timely discharge planning.  Coordinates information between third party payers and medical/clinical staff members.  Interacts with members of the medical/clinical team to provide a flow of communication and a medical record which documents and supports level and intensity of service rendered.  All duties to be done in accordance with Joint Commission, Federal and State regulations, Oceans' Mission, policies and procedures and Performance Improvement Standards.

Essential Functions:

1. Identifies and reports appropriate use, under-use, over-use and inefficient use of services and resources to ensure high quality patient care is provided in the least restrictive environment and in a cost-effective manner.
2. Conducts review of all inpatient, partial hospitalization, and outpatient records as outlined in the Utilization Review/Case Management plan to (1) determine appropriateness and clinical necessity of admissions, continued stay, and or rehabilitation, and discharge; (2) determine timeliness of assessments and evaluations; i.e. H&Ps, psychiatric evaluation, CIA formulation, and discharge summaries; and (3) identify any under-, over-, and/or inefficient use of services or resources.
3. Reports findings to appropriate disciplines and/or committees; notifies appropriate staff members of any deficiencies noted so corrective actions can be taken in a timely manner; submits monthly report to PI Coordinator of findings and actions recommended to correct identified problems.
4. Coordinates flow of communication between physicians/staff and third party payers concerning reimbursement requisites
5. Attends mini-treatment team and morning status meetings each weekday to obtain third-party payer pre-certification and ongoing certification requirements and to share with those attending any pertinent data from third-party payer contracts.
6. Attends weekly treatment team.
7. Conducts telephone reviews to, and follows through with documentation requests from third party payers.
8. Maintains abstract with updates provided to third party payers.
9. Notifies physicians/staff/patients of reimbursement issues.
10. Initiates and completes appeals process for reimbursement denials; notifies inpatients of denials received.
11. Reports monthly all Hospital Issued Notices of Non-coverage (HINN letter) to QIO.
12. Conducts special retrospective studies/audits when need is determined by M&PS and /or other committee structure.
13. Ensures all authorization and denied information is in HCS at the end of each business day.
14. Meets with patients at start of stay to discuss precipitating factors for admission and to discuss discharge planning
15. Reaches out to family/caregiver as consented by the patient for collateral information.
16. Schedules discharge appointments to the appropriate level of care as decided by the team.
17. Completes all paperwork related to discharge planning to include regular notes in the chart pertaining to conversations with patients, family, caregiver and discharge provider and required documentation of the hospital policy.
18. Performs other duties and projects as assigned.