Regional Utilization Review Coordinator

Overview

Under the general supervision of the Regional Director of Utilization Review, the Regional Utilization Review Coordinator is responsible for overseeing and coordinating the utilization review processes across multiple healthcare facilities within the region. This role ensures that patient care is delivered efficiently and effectively, while maintaining compliance with regulatory standards and optimizing resource utilization. Applies review criteria to determine medical necessity for admission and continued stay.

Ensures the delivery of cost-effective quality healthcare and assists in the identification of appropriate utilization of resources across the continuum of care. This role involves working in a fast-paced environment with tight deadlines and changing priorities. Works collaboratively with interdisciplinary staff internal and external to the organization.

• Implement the utilization management process for patients admitted to acute level of care.
• Conduct concurrent clinical reviews for utilization/quality management activities based on acute care guidelines focusing on appropriateness of admission, monitoring length of stay, and discharge delays.
• Provide appropriate reviews to multiple health plans/medical groups via agreed methods (telephone, fax, insurance portals).
• Oversee utilization reviews to ensure appropriate use of medical services and resources. Evaluate patient care plans and medical records to determine the necessity and efficiency of services provided.
• Provide retro review of identified cases denied by health plans for financial reimbursement.
• Submit notification of admission and obtain timely authorizations for care from health plans as needed.
• Analyze and identify utilization patterns and trends of ancillary services as part of inpatient and observation visits and participate in the collection and analysis of data for the denial process as well as special studies, projects, audits, routine utilization monitoring activities.
• Work under the guidance of and in collaboration with the hospital utilization review committee to maintain appropriate standards of utilization review and support the implementation of the hospital utilization review plan.
• Ensure compliance with all federal, state, and local regulations, as well as organization policies and procedures. Maintain up-to-date knowledge of regulatory agency guidelines as they pertain to area of practice.
• Function as key resource provider related to utilization review, delivery of care, and effects of reimbursement on both patients and health care system.
• Identify avoidable delays or days and assist in the collection of data to trend and analyze outcomes for identification of improvement opportunities.
• Maintain work standards that are in compliance with ARH’s policies and governmental regulations and various regulatory agency requirements.
• Work closely with healthcare providers, case managers, and other stakeholders to facilitate effective communication and coordination of care.
• Collaborate with the System Director of Case Management and other regional coordinators to develop and implement best practices.
• Demonstrate consistent professional commitment to institution and department goals and objectives, flexibility to department needs, and willingness to extend oneself when needed.
• Attend and/or complete all required safety training programs and describe responsibilities related to general safety, department/service safety, and specific job-related hazards.
• Demonstrate respect and regard for the dignity of all patients, families, visitors, and employees to ensure a professional, responsible, and courteous environment.

LPN or RN graduated from an accredited school of nursing with a state license to practice professional nursing in state of resident facility. BSN preferred. Previous experience in utilization review and/or case management preferred. Working knowledge of federal, state, and regulatory requirements in quality assessment, case management, resource management, hospital systems, accreditation, and licensure strongly preferred. Willing to obtain licensure in additional states…