Utilization Review Coordinator (Rn), Behavioral Health-Per Diem

STATEMENT OF PURPOSE

This position supports the Mission of the Hospital through the provision of distinctive and compassionate care to our patients. The Utilization Review Coordinator will monitor adherence to the hospital's utilization review plan to ensure the effective and efficient use of hospital services and monitor the appropriateness of hospital admissions and extended hospitals stays. Perform various clerical tasks utilizing knowledge of office systems and procedures, facility regulations, and interdepartmental functions.

• Job Specific Accountabilities

• Assists the Utilization Review Committee in the assessment and resolution of utilization review problems.
• Refers to the Utilization Review Physician Advisor cases that do not meet established guidelines for admission or continued stay.
• Establishes and maintains efficient methods of ensuring the medical necessity and appropriateness of hospital admissions.
• Compiles monthly reports and statistics for presentation to the Utilization Review Committee.
• Assists with studies, reports and projects as requested
• Monitors Medical case lists in Revenue Cycle on weekly basis, at least, to verify the status of TARS needed to be completed and status on TARS needing appeals and follows up to process timely
• Maintains communication with the Social Behavioral Health Department to facilitate timely discharge planning.
• Identifies problems related to the quality of patient care and refers them to the Quality Assurance Committee.
• Calculates the lengths of stay and continued-stay days for patients.
• Regularly attends required in-services and continuously takes an active interest in furthering one's knowledge.
• Accurately files, types, faxes and Xeroxes when necessary
• Coordinates and supervises the activities of the Utilization Review Department.
• Responsible for processing all TARS in BHU after patient discharges. Including:
• Constructs correspondence, memos and reports of professional quality
• Confirms Medical TARS are completed for all dates of service and requests follow-up from the case managers, including clinical write up, as needed.
• Demonstrates knowledge and skill set to process BHU Medical TARS
• Prints the complete medical record utilizing TAR report template in EMR. Assemble chart. Complete IS, complete TAR, and audit TAR to ensure TAR is accurately completed.
• Performs concurrent reviews for patients to ensure that extended stays are medically justified and are so documented in patient's medical records.
• Prepare face sheets and print eligibility for patients. Coordinates with HIM to request necessary medical records.
• Assemble and maintain departmental files, logs, and manuals, and assures proper maintenance of same, as needed and as directed by the UR supervisor or Director of Behavioral Health.
• Has the willingness and ability to perform all other duties and responsibilities as assigned
• At the direction of Director of Behavioral Health or the Manger for Behavioral Health, compiles, maintains and disseminates Medical Denial statistical data and reports ( i.e. TAR denial and TAR summary reports) on weekly and monthly basis.
• Submit Medical TAR to Medical field office via courier on designated days of workweek post discharge of patient
• Prepares Medical appeal decisions involving upheld denied days for further appeal by providing Director of Case Management or Supervisor the original TAR, original adjudication response, appeal letter decision and face sheet for submission to contracted vendor to appeal further
• Processes adjudication responses and appeal decisions from Medical, upon receipt to case management, to include date stamp the date received and log all cases decisions on Medical log
• All other duties as assigned. May be required to cross train and work within scope of service in other areas within the Coast Plaza Hospital’s Behavioral Health Unit.
• Completes data entry in Revenue Cycle of Cerner software to document TARS submission to MCal TAR Field office, TAR denials, and appeal submission to DMH. Maintaining documentation in appropriate queue in the Revenue cycle depending on status of account.

Qualifications:

• Possesses skill set to provide clerical support to the Case Management Department.
• Current CPR BLS for healthcare provider’s card upon hire
• Excellent verbal and written communication skills. to interact appropriately with providers, other departments in the hospital and outside facilities/vendors
• Ability to demonstrate knowledge and skills necessary to provide care appropriate to the age served on the unit. Possess knowledge of growth and development over the life span.
• Computer literate with ability to use Microsoft Office applications required. Performs all job duties in a professional manner. Bilingual (English/Spanish) preferred.
• Knowledge of Medical terminology required
• Five years + experience in acute care hospital Utilization Review and RN Required
• Excellent time management skills with a proven ability to meet deadlines.
• Excellent verbal and written communication skills.
• Excellent organizational skills and attention to detail.