UTILIZATION REVIEW COORDINATOR - UTILIZATION REVIEW
Utilization Review Coordinator
Purpose: The purpose of this position is to work with Clinic and ER Physicians to monitor adherence to hospital Utilization Review plan to ensure the effective and efficient use of hospital services. To monitor the appropriateness of hospital admissions and extended hospital stays. Monitors proper usage of resources based on admission criteria and reimbursement.
•Establishes and maintains efficient methods of ensuring the medical necessity and appropriateness of all hospital admissions.
•Establish and carry out a program of admission and extended stay review of all admissions.
•Performs concurrent reviews for patients to ensure that extended stays are medically justified and are so documented in patient's medical records.
•Communicate with physicians, as needed, to decrease over-usage of hospital resources and to keep the physicians informed of any changes in the conditions of participation for UR.
•Consults with the ER Physician and/or Admitting Physician for all cases that meet or do not meet established guidelines for admission or continued stay during normal business hours.
• Maintain close liaison with your Department Director as well as other agencies to assist in ongoing modification of criteria and standards.
•Recommend changes in the hospital procedures or medical staff practices as indicated on the analysis of review findings.
•Review and submit summary of questionable admissions and readmissions to the UR Committee.
•Monitor trends in transfers to other acute care facilities as well as transfers from other acute care facilities.
•Assists the Utilization Review Committee in the assessment and solution of identified utilization review problems.
•Review all patient stays and once they exceed the benchmark Length of Stay for their diagnosis, refer to physician advisor for review. Report findings to the UR Committee.
•Prepare adverse determination notice as deemed necessary utilizing current criteria and established policies and procedures.
•Communicate with Nursing Services daily in regard to any outliers in order to improve timeliness of patient discharge.
•Review all patients daily for excessive length of stay and cost.
• Serve as liaison to ER Physicians/Medical Staff.
• Maintain individual and aggregate patient data with respect to admission and extended stay review, transfers, outliers, etc., and report to UR Committee.
•Examine findings from Quality Improvement monitoring activity to identify utilization problems and participate on Quality Improvement Committee as directed.
•Assists the Acute Care Director and Swing Bed Coordinator in chart review of referrals as needed.
•Maintain a liaison with Social Services to facilitate timely discharge planning.
•Assumes the responsibilities of the Swing Bed Coordinator in his/her absence and Social Services discharge planning
• Participates in staff conferences along with the Swing Bed Coordinator, Acute Care Director, Nursing Services, Therapy Services, as needed to ensure that upon leaving the facility, each patient has a plan of continuity of care.
•Compiles reports and statistics for presentation to the Utilization Review Committee at least quarterly.
•Submit Utilization Review plan annually to the State of Missouri to comply with pertinent state and federal regulations.
•Encourages appropriate utilization of Medicare services.
•Conducts an annual review of Medicare Condition's of Participation, and as needed with updates.
•Other related duties and responsibilities that may become necessary or as directed by your Department Director and/or Administrator.
•General hospital environment
Academic, Certifications, & Trade Qualifications
•Graduate of an approved RN program
•Current, unencumbered license to practice as an RN in the State of Missouri
Work Experience, Skills, and Strengths
•Must have at least two years experience in general nursing.
•Must have background experience in medical terminology, lab values, medications, etc.
•Basic knowledge of Medicare, Medicaid, Insurance, etc., rules, regulations, and guidelines is preferred
•Must have basic knowledge of coding, diagnoses, and operations.
•Must be able to bend, stoop, lift at least 50 pounds, and move intermittently throughout the work day including standing, walking, sitting, lifting, turning, carrying, pushing, pulling, stooping, crouching, twisting, reaching
•Must possess sight/hearing senses, or use prosthetics that will enable these senses to function adequately so that the requirements of this position can be fully met
•May be required to lift equipment, supplies, etc.
•May be subjected to infectious diseases, waste, conditions, etc., including the potential exposure to the AIDS, Tuberculosis and Hepatitis B Viruses
The Ideal Candidate
•The ideal candidate has friendly and compassionate personality with experience in Utilization Review, and is able to assist for a variety of patients who may have different mental capabilities, sometimes requiring creativity, in a professional manner and/or displays the aptitude to perform in this manner.
Position Type : Full Time
Salem Memorial District Hospital
35629 Highway 72
Salem, MO 65560