Utilization Review Coordinator

Job Summary

Utilization review specialist works to improve patient care through effective utilization and monitoring of care outcomes. Skills needed to include excellent written/verbal communication skills, critical thinking skills, creative problem-solving, proficient planning, process improvement, and auditing and leadership skills. Must be self-directed, collaborative, resourceful, have the ability to tolerate frequent interruptions and a demanding workload. Knowledge of funding, resources, services, clinical standards, and outcomes is preferred.

Is proactive, with the team, to achieve desired clinical, financial, and resource outcomes. Actively participates in compliance with The Joint Commission standards, processing the AR cycle, fiscal stability and Length of Stay efforts of the Hospital.

Requirements: Laptop with functioning internet connection and access to EMR and Allscripts

Expectation: Complete at least 30 reviews during the remote UR workday.

Job Duties

• Complete all inpatient admission and observation reviews for all medical inpatient units, with priority being inpatient admissions with commercial insurance.
• Liaise with payer rep to assess if any daily reviews have already been requested by insurance for patients that are still in-house, and to obtain contact information if not prepopulated in Allscripts Care Manager.
• Complete all daily reviews for patients with per diem insurance such as Horizon Blue Cross, Blue Shield of California, etc as able.
• If time does not allow, the in-hospital case managers assigned to each unit would be notified early enough in the day to allow for completion.
• Notify the manager or the covering supervisor of task completion by email, and include if any reviews were not able to be completed/sent, as well as reason(s) why, such as incomplete provider notes.
• Assists the Director with developing specific departmental goals, standards, and objectives which directly support the strategic plan and vision of the organization as requested
• Assesses the quality of patient care delivered and coordinates patient care services with patients, staff, physicians, and other departments.
• Assists with the denials process with focus on clinical reviews, peer-to peer reviews, payer communications, tracking and other duties related to denials and denials prevention.
• Other duties as assigned.

Requirements

• Bachelor's degree in Nursing
• 2 years of related experience
• State licensure as a Registered Nurse (RN)
• Preferred: Master's degree in Nursing

Leadership Skill Requirements:

• Maintain and Model Respect, Excellence, Accountability, Compassion and Honor.
• Action and Results-Oriented: Ability to establish key goals, drive and track results among multiple decision-makers and stakeholders and meet deadlines in a fast-moving environment.
• Political Savvy and Diplomacy:
  • The ability to maneuver through complex, politically charged situations and understand the dynamics and culture of the organization.
  • The ability to anticipate problems and negotiate solutions with peers, senior leadership, and other key stakeholders.
  • Ability to Build Relationships Through Integrity and Trust
  • The ability to quickly gain the trust and respect of others, drive collaboration, build a teamwork environment, search for win/win scenarios.
• Influencing Skills: Ability to lead an organization using influence, rather than possessing direct authority of others, being sensitive, yet direct in both verbal and written communications.
• Managing Complexity: Ability to lead and drive results in a complex organization, achieving alignment between often-conflicting priorities, initiatives and people.

Functional/Technical Skills Requirements:

• Comprehensive understanding of operational health care delivery systems and the current health care landscape. Skills and experience with developing competitive business strategies for health care. Skills and experience with the operational aspects of health care technology deployment. Familiarity and comfort with technology-based operational improvement. Health care management or consulting experience preferred.
• Analytics and Strategy: Expertise in developing and executing data-driven approaches to enhancing business decision-making and improving operational performance (preferably in healthcare). Advanced knowledge of business intelligence best practices, familiarity with fact-based management tools and techniques to drive strategies and a continuous improvement culture.
• Communications: Excellent written and verbal communications skills. Ability to take abstract, complex and/or technical information and break it down for a variety of audiences in a way that is meaningful for them.
• Functional Oversight: Issue identification, gap analysis, ability to prioritize business needs and execute solutions.
• Financial Management: Ability to understand financial reports, develop basic financial models, and identify trends, variances, and opportunities.