What are the responsibilities and job description for the Utilization Review Coordinator position at CareWell Health?
The Utilization Review Coordinator is responsible for ensuring that patients receive appropriate, cost-effective care by reviewing medical records, treatment plans, and healthcare services. The role involves collaborating with healthcare providers and an interdisciplinary team to optimize resource utilization and improve patient outcomes. The Utilization Review Coordinator ensures parties follow the Joint Commission standards, authorizations and medical necessity, fiscal stability through denials review, and monitors length of stay efforts of the hospital.
Essential Functions
- Conduct detailed reviews of patient medical records to ensure treatments and services meet established guidelines and criteria.
- Assess the appropriateness of proposed treatment plans and recommend modifications to enhance patient care and resource efficiency.
- 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.
- Complete all inpatient admission and observation reviews for all inpatient units, with priority to observation cases and denied inpatient admissions with commercial insurance.
- Provide education and support to healthcare staff regarding utilization review processes, best practices, and regulatory requirements.
- Participate in quality improvement initiatives, contributing to the development and implementation of utilization review policies and procedures.
- Maintain comprehensive and accurate documentation of all reviews, authorizations, and communications with healthcare providers and insurance companies.
- Assists the Director of Quality with developing specific departmental goals, standards, and objectives which directly support the strategic plan and vision of the organization as requested
- Other duties as assigned.
Functional/Technical Skills Requirements:
- Comprehensive understanding of operational healthcare delivery systems and the current healthcare landscape. Skills and experience with developing competitive business strategies for healthcare and operational aspects of healthcare technology deployment. Familiarity and comfort with technology-based operational improvement.
- 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 effectively convey the message for a variety of audiences at their level of comprehension.
- Functional Oversight: Issue identification, gap analysis, ability to prioritize business needs and execute solutions.
- Technology: Proficient in the use of healthcare technology. Skilled in technology-based operational improvement: auditing, data aggregation, monitoring.
Minimum Education/Certification:
Knowledge of New Jersey and national quality management and regulatory standards, including reporting.
Bachelor's degree in Nursing, Healthcare Administration, or a related field
Current RN license or equivalent clinical certification preferred
Master's degree in healthcare
Medical record review experience preferred.
Project Coordination / Project Management experience preferred.
Minimum Work Experience:
Required 1 year of experience in quality improvement and/or utilization review in an acute care setting.
Minimum of 2 years of related experience in utilization review, case management, or related field
