Job Summary:

The Utilization Review Coordinator is responsible for assessing medical records to determine appropriateness and medical necessity of admissions, continued stay, and use of ancillary services (EX: Radiology; Misc. Labs; etc).  Responsible for ensuring compliance with payer guidelines and maximizing cost-effectiveness while upholding quality patient care.  Communicates with physicians, head nurse, nursing staff, therapists and other disciplines when necessary.  The role requires communicating with providers and making informed decisions regarding authorization of services based on established criteria.

Duties and Responsibilities:

 Clinical:

• Conduct through reviews of patient medical records to evaluate the medical necessity of proposed treatments, admissions, and continued stays, utilizing established clinical guidelines and criteria. Must be familiar with InterQual and MCG Health Guidelines.
• Analyze diagnostic test results, progress notes, and other relevant clinical data to determine appropriateness of care.

• Contact healthcare providers to gather additional information when necessary to make informed decisions.
• Communicate with billing office staff to verify health care insurance carriers including Blue Cross, HMOs, Medicare, VA and MA payor types as necessary.
• Maintain a system of monitoring all admission, concurrent and extended reviews to assure the extended reviews are done in a timely manner.

• Communicate authorization decisions to providers and patients in a clear and timely manner, explaining rationale for decisions.
• Effectively manage appeals related to denied services, providing detailed clinical justifications when necessary.
• Check admission orders daily for level of care orders and verify with billing office as needed.
• Complete charges for Observation admissions daily and submit to appropriate staff.
• Assist in Discharge Planning when necessary and arrange for outpatient services needed upon discharge.

Data Analysis and Reporting:

• Track and analyze utilization trends to identify areas for improvement and cost-saving opportunities.
• Generate reports on utilization review activities, including denial rates, average length of stay, and key performance indicators.
• Collaborate with the Utilization Committee to develop and implement strategies to optimize resource utilization.
• Schedule quarterly Utilization Review Committee meetings to discuss data, pending retrospective denials, length of stay denial reports, KPI Project review and other topics involving utilization review policies and procedures.

Compliance and Quality Assurance:

• Stay updated on current healthcare regulations, payer guidelines, and industry standards related to utilization review.
• Adhere to all hospital policies and procedures regarding patient confidentiality and data integrity.
• Participate in quality improvement initiatives to ensure high-quality patient care.

Collaboration and Communications:

• Maintain open communication with healthcare providers, discharge planning, and other stakeholders to coordinate patient care effectively.
• Foster positive working relationships with internal and external teams to facilitate timely and efficient utilization reviews.
• Participate in weekly Transitional Care team meetings and TEAMS meetings when scheduled communicating status of patient authorizations/denials/length of stay.

Required Qualifications:

• Registered Nurse (RN) or other relevant healthcare professional license
• Minimum of 2 years of clinical experience in an acute care setting with knowledge of medical necessity review principles and utilization management practices
• Strong understanding of medical terminology and clinical practice guidelines
• Knowledge of healthcare insurance policies and reimbursement methodologies
• Excellent analytical and problem-solving skills
• Strong communication and interpersonal skills to effectively interact with healthcare providers and patients
• Proficiency with electronic health records and utilization review software