The Utilization Management Coordinator coordinates and monitors daily activities of the utilization management functions of the Care Coordination department, ensuring the appropriate allocation of hospital resources while maintaining quality of patient care. This position also holds the responsibility for ensuring regulatory compliance requirements and coordinating the medical management aspects of clinical review requests from external entities.
Performs chart reviews for appropriateness of admission and continued hospital stay applying appropriate clinical criteria. Provides concurrent and retrospective clinical information to the insurance company within 24 hours or first business day of admission or request. Refers days for appeal to the physician advisor upon notification of denial. Documents identified avoidable, denied and alternate level of care days appropriately. Documents physician advisor’s response to referral, final determination and certification of hospital days. Demonstrates effective communication skills with physicians, patients and families, insurance companies, and all the disciplines through the continuum of care.
Active RN license
Case Management / Utilization Management experience preferred
At least 5 years of RN experience
Good communication and interpersonal skills