Under general supervision, the Utilization Review Coordinator provides professional assessment, planning, coordination, implementation and reporting of complex clinical data and supports the operations of Samaritan Behavioral Center.

The Utilization Review Coordinator reviews the patient's chart and records clinical information and criteria. He/she will identify areas in the charts that need improvement. He/she will use his/her skills to help educate the staff and physicians regarding charting.

REPORTS TO: Utilization Review Lead/Manager

QUALIFICATIONS:

• High School Diploma or equivalent.

• Bachelor of Arts or Bachelor of Science Degree (preferred).

• A minimum of one (1) year of experience in a managed behavioral healthcare facility. (Preferred)

• Ability to communicate in English, both verbally and in writing.

• Basic computer skills.

REQUIREMENTS FOR POSITION:

Hearing: Hearing acuity sufficient to perform job functions.

Speaking: Able to articulate goals and objectives of the Center and to effectively present information to management, committees, staff, patients, families, and licensing and regulating agencies.

Vision: Normal visual acuity.

Writing: Excellent written communication skills needed to prepare reports, write policies and procedures, document in-patient records, prepare agenda and minutes for department meetings and carry out Performance Improvement Planning and monitoring.

Other: Organizational skills, writing skills, Basic computer skills.

PHYSICAL DEMANDS:

• Physical: Lifting 40 lbs.

• Pushing up to: 100 lbs.

• Manual Dexterity: Average

• Average % of time during regular shift devoted to:

  Standing: 0-30 Walking: 21-30

  Sitting: 21-30 Squatting: 0-10

AGE(s) OF PATIENTS SERVED AND AGE-SPECIFIC TECHNLOGY:

Adult Population: Age 18 and up

Knowledge of Principles of Growth and Development including adult and geriatric in order to carry out utilization review responsibilities.

DUTIES AND RESPONSIBILITIES:

The duties set forth below describe the general nature and level of work being performed by the URC. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of the URC since those duties include all tasks requested by the UR Manager, CEO or Medical Director to meet the needs of the Center.

Perform utilization review in accordance with all state mandated regulations. Maintains compliancy with regulation changes affecting utilization management. Reviews patient recrods and evaluates patient progress. Performs continuing review on medical records and identification and need of on-going hospitalization. Obtains and reviews necessary medical reports and subsequent treatment plan requests to conduct review. Ensures appropriate and cost-effective healthcare services to patients.

Documents review information in the HMS. Communicates results to the case management entity for the specific insurance payer. Enters billing information for services. Receives and processes requests for appeal of denials. Responds to complaints per UR guidelines. Maintains utilization review and appeal logs, as needed.

Analyzes patient recrods and participates in interdisciplinary collaboration with professional staff. Facilitates education programs and advises physicians and other departments of regulations affecting utilization management. Consults with Social Services Department regarding the level of nursing care and collaborates with other departments in evaluation of projects affecting discharge plans.

Supports clinical improvement activities of Samaritan Behavioral Center by providing quality review. Records and reports all information within the scope of authority.

Performs other duties as assigned or required.

Knowledge and Skills:

• medical/psychiatric terminology, anatomy, physiology and concepts of disease

• CMS standards of 401 criteria for both admission and continued stay

• Conducting and reviewing medical records for medical necessity

• Basic ICD-9, CPT coding knowledge

• Regulations as set by the Centers for Medicare/Medicaid Services

• Skill in operating a personal computer utilizing a variety of software applications

• Strong written and oral communication skills

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