Utilization Review Coordinator (Inpt Psych)

Provides assistance to various medical staff and Medical Center personnel relative to utilization review activities through concurrent and retrospective review, screening for discharge planning indicators, identification of potential quality of care concerns, understanding of health care benefit inclusions/exclusions to ensure high quality patient care and maximized reimbursement for rendered services. Participates in quality management and continuous quality improve Hurley Family Standards of Behavior. Works under the direction of the Director of Case Management or designee who reviews work for effectiveness and compliance with established standards, policies, and procedures.

1. Performs concurrent and retrospective utilization review including admission certification, continued stay review, care level determinations, resource usage monitoring and other criteria associated with utilization review. Confers and follows-up with physicians to review admissions and continued stays not meeting criteria.


2. Reviews quality of care rendered to each patient. Initiates referrals through established quality process. Intervenes to facilitate changes. Screens for potential risk management and infection control issues.


3. Screens each reviewed patient for potential discharge planning needs. Refers to and follows-up with Case Management or other appropriate staff/services.


4. Stays abreast of health care benefit inclusions and exclusions for all financial classes, benefit changes, review requirements, and other pertinent regulations influencing the Medical Center.


5. Issues notifications to hospitalized patients, patient families and physicians regarding cessation of benefits for continued hospital care. Monitors all external managed care program concurrent denials to ensure optimal patient care and rights.


6. Conducts appeals of denied days by third-party reviewers throughout each stage of available reconsideration/appeal mechanisms.


7. Reviews charts for instances of over/under utilization of ancillary services to ensure optimum quality of care and maximum reimbursement.


8. Interfaces with Patient Accounting, Medical Records, and others to ensure post discharge completion of all information necessary to generate timely billing.


9. Acts as resource for utilization review; provides educational sessions through oral presentations for medical/ancillary staff as assigned.


10. Performs and assists in authorized research efforts under the direction of medical staff and committees. Retrieves, analyzes and displays data. Abstracts information medical record. Reviews for completeness and consistency of content.


11. Drafts letters to third-party review entities and medical staff members. Prepares routine and special reports/summaries.


12. Assists in identification, development, and implementation of new procedures designed to increase operating efficiency.


13. Participates in the development of departmental goals and objectives relative to utilization review. Establishes quality control mechanisms for assigned areas of responsibility.


14. Appeals cases in order to ascertain payment for the hospital.


15. Reviews level of care for patients (with medical staff approval) regarding inpatient, observation, outpatient care and relates this information to the Patient Business Services for billing purposes.


16. Reviews the DNFB in order to ensure bills are forwarded in the revenue cycle to hospital billing.


17. Works in conjunction with case managers in order to provide correct services to the patient.