Utilization Review Technician conducts utilization reviews to determine if patients are receiving care appropriate to illness or condition. Monitors patient charts and records to evaluate care concurrent with the patients treatment. Being a Utilization Review Technician reviews treatment plans and status of approvals from insurers. Collects and complies data as required and according to applicable policies and regulations. Additionally, Utilization Review Technician consults with nurses and physicians as needed. Position is non-RN. May require an associate degree or its equivalent. Typically reports to a supervisor. May require Registered Health Information Technician (RHIT). The Utilization Review Technician gains exposure to some of the complex tasks within the job function. Occasionally directed in several aspects of the work. To be a Utilization Review Technician typically requires 2 to 4 years of related experience. (Copyright 2024 Salary.com)
Reviews, ensures, and maintains inpatient medical records concurrently and retroactively for medical necessity and for quality of care/risk management issues. Advises and provides consultation to physicians and staff regarding appropriate and efficient utilization of hospital resources. Facilitates complex case management. Reports pertinent quality improvement (QI) concerns to the supervisor and physician regarding utilization of clinical resources, inappropriate admissions and denials of services by third party payers. Initiates the process to appeal denials and discrepancies on code assignments. The Case Management supports the operations of Southwest Health System, by managing discharge planning for patients utilizing an interdisciplinary approach with consideration of maximizing the functional level of patients post hospital care. The Case Management individual facilitates and promotes patient management and utilization review. The Care Management individual is a professional who coordinates with the interdisciplinary team, patient/family on complex aspects of the patients' care and serves as the focal communication point for patients and staff. The Case Management works closely with the providers(s), nurses, and other members of the team internal and external throughout the continuum of care for patients. The Case Management staff works in conjunction with the interdisciplinary team and is accountable for assessing the discharge plan for effective and efficient utilization of resources, meeting established professional and regulatory standards, and who collaborates with the healthcare team and the patient/family to accomplish agreeable outcomes. The Case Management uses a proactive approach, acts as a liaison between SHS and external resources for appropriate placement and/or follow up care.
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** THIS POSITION WILL REMAIN OPEN FOR A MINIMUM OF 5 DAYS. AFTER THAT DATE, THE POSITION WILL CLOSE WHEN A SUITABLE CANDIDATE IS SELECTED. **
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