System One Services Utilization Review Coordinator (RN or LPN) in Craig, Colorado
Utilization Review Coordinator (RN or LPN)Craig, CO
Joule' Healthcare is seeking a Utilization Review coordinator for an established healthcare organization in Moffatt County, CO. The Utilization Review Coordinator conducts utilization reviews to determine if patients are receiving care appropriate to illness, disease process, or condition. Reviews can take place as prospective, concurrent, and retrospective in nature. The Utilization Review Coordinator will use a software program to upload patient data for review and evaluation to ensure appropriate utilization services provided by medical staff to patients, particularly those patients entitled to benefits under both Medicare and Medicaid.
Essential Functions and Basic Duties
Position Specific Performance Expectations:
Track patient cases from admission to discharge.
Gathers pertinent clinical information and applies and interprets criteria to ensure medical necessity, covered benefits, participating providers and appropriate services.
Ability to use critical thinking skills supporting patients in accessing all necessary applicable resources for follow-up care:
From admission (regardless of status) ensures that patients are “pre-qualified” for hospital admissions.
Continued admission (regardless of status) ensures that patients are “re-qualified” for hospital admissions.
Conducts appeals on behalf of the patient and family (at time of service and for hospital stay denials).
Understands Inpatient, Observation, Transition Care, Swing Bed admission status’ and can discern and explain which resource may be best for a specific patient based on diagnosis and level of acuity.
Ability to advocate for patients, and negotiate with physician and ancillary staff for patients.
Ability to advocate for patients with insurance companies and CMS for additional services.
Expert at InterQual and/or Millimen and/or MCG clinical decision-support criteria.
Advocate that the patient is placed in the appropriate level of care and program.
Interface with program staff to facilitate a smooth transition at the time of transfer or discharge.
Monitors patient charts and records to evaluate care concurrent with the patient’s treatment.
Reviews treatment plans and status of approvals from insurers.
Facilitates and coordinates discharge planning and works towards reduction of preventable hospital admissions, re-admissions, etc.
Work closely with Revenue Cycle Department to ensure the insurance precertification process is complete and to update the denial log statistics on an ongoing basis (at least weekly), and initiate appeals through telephone or written communication within 7 to 10 days of denial.
- Minimum 2 years of experience in an acute care setting preferred
Licenses & Certifications
Registered Nurse Colorado
Licensed Practical Nurse