Clinical Utilization Review Coordinator

Job Title:

Clinical Utilization Review Coordinator Department:
Nursing

Reports To:

Chief Nursing Officer Clinical Utilization Review Coordinator

Position Summary:

The Clinical Utilization Review Coordinator is responsible for evaluating the medical necessity, appropriateness, and efficient use of hospital resources for inpatient, observation, outpatient treatment room, outpatient surgery, and other applicable services. Responsibilities include utilization review, prior authorizations, care coordination and discharge planning, quality data abstraction, and assisting with scheduling and Swing Bed Coordination as needed.

The Coordinator collaborates with physicians, hospital departments, payers, and external review agencies to support appropriate levels of care, regulatory and payer compliance, effective transitions of care, quality patient outcomes, and appropriate reimbursement. The position monitors utilization trends, identifies opportunities for improvement, and provides data, reports, and recommendations to support efficient resource utilization, quality improvement, and patient safety.

Summary:

Reviews of the utilization of hospital resources against established criteria documentation requirements of external agencies. Monitors and evaluates necessity, appropriateness, and efficient use of health care services. Provides reports and recommendations to medical and hospital staff for improved utilization of resources and to maximize reimbursement while maintaining quality care.

Essential Duties and Responsibilities The following duties and responsibilities are considered essential to the position. Other duties may be assigned.

Performs utilization reviews for inpatient, observation, outpatient treatment room, outpatient surgery, and other applicable services to assess medical necessity, admission status, level of care, and continued-stay appropriateness using established criteria and payer requirements.

Reviews clinical documentation for compliance with regulatory and payer requirements; identifies cases not meeting established criteria and coordinates referrals to the physician advisor or designated medical staff for further review.

Coordinates and obtains prior authorizations for applicable services and communicates with payers and external review agencies regarding authorizations, medical necessity, level of care, continued stays, and denials.

Coordinates and assists with discharge planning, care coordination, and transitions of care in collaboration with physicians, nursing, Social Services, Case Management, and other departments to support appropriate, timely, and effective patient care.

Assists with Swing Bed Coordination and serves as backup Swing Bed Coordinator in their absence.

Assists with scheduling services, procedures, or appointments as needed to support patient care and departmental operations.

Performs quality data abstraction in collaboration with the Director of Quality and Risk Management; identifies and reports quality, infection prevention, patient safety, risk management, and other concerns identified through record reviews.

Compiles and analyzes utilization data, authorization outcomes, denials, trends, and other required reports; provides recommendations to support appropriate resource utilization, reimbursement, documentation, and quality improvement.

Collaborates with the physician advisor, medical staff, Business Office, Patient Registration, and other internal and external stakeholders to address utilization concerns, documentation needs, payer requirements, and opportunities for improvement.

Provides education to hospital employees and medical staff regarding utilization review processes, medical necessity criteria, prior authorization requirements, documentation…