Utilization Review Coordinator
Company: Oceans Healthcare
Posted on: May 13, 2022
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.
- 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.
- 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.
- 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.
- Coordinates flow of communication between physicians/staff and
third party payers concerning reimbursement requisites
- 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.
- Attends weekly treatment team.
- Conducts telephone reviews to, and follows through with
documentation requests from third party payers.
- Maintains abstract with updates provided to third party payers.
- Notifies physicians/staff/patients of reimbursement issues.
- Initiates and completes appeals process for reimbursement
denials; notifies inpatients of denials received.
- Reports monthly all Hospital Issued Notices of Non-coverage
(HINN letter) to QIO.
- Conducts special retrospective studies/audits when need is
determined by M&PS and /or other committee structure.
- Ensures all authorization and denied information is in HCS at
the end of each business day.
- Performs other duties and projects as
assigned.RequirementsEducational / Experience
Requirements:Associate's Degree with emphasis on healthcare or
Bachelor's degree in social services field preferred. At least one
year psychiatric/chemical dependency experience with good working
Qualifications/Skills:Must have excellent assertive communication
skills. Knowledge and in-depth understanding of CD-psych treatment
and discharge planning process. Must have good writing and
composition skills. Must have good understanding of regulatory and
fiscal reimbursement and utilization review as a primary component
of patient care. Must demonstrate strong patient advocacy skills.
Must be able to organize and prioritize high volume workload. Must
be able to analyze and utilize data and systems to provide
individualized quality treatment in a cost-effective manner. Must
be able to function with minimal supervision. Therapeutic
Intervention De-escalation Education required. Must have ability to
maintain overall good work attitude and interact cooperatively and
professionally with other staff members and third party payers to
achieve mutually beneficial outcome. Must possess basic competency
in age, disability, and cultural diversity for needs of patients
served and ability to relate to patients in a manner sensitive to
those needs. Must successfully complete CPR certification and an
Oceans approved behavioral health de-escalation program.
Work Environment:Subject to many interruptions. Occasional pressure
due to multiple calls and inquiries. This position can be high
paced and stressful; must be able to cope mentally and physically
to atmosphere. Work requires spending approximately 90% or more of
the time inside a building that offers protection from weather
conditions but not necessarily from temperature changes.
Keywords: Oceans Healthcare, Lafayette , Utilization Review Coordinator, Other , Broussard, Louisiana
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