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COORD - CASE MGMT/UTILIZ REV - (14093)

Universal Health Services


Date:
12/14/2017
2017-12-142018-01-12
Job Code:
14093
Universal Health Services
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Job Details

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Job Details


COORD - CASE MGMT/UTILIZ REV - (14093)

Facility Name
LIGHTHOUSE BEHAVIORAL HEALTH HOSPITAL
Location
CONWAY, SC 29526 US (Primary)
Career Area
Professional
Category
Finance, Registered Nurse (RN)
Job Description

:Job Summary:  The UR Coordinator is responsible for conducting utilization and quality management activities in accordance with company policy.  The Coordinator performs the overall function of providing an ongoing, systematic process for the measurement and assessment of the necessity, appropriateness, and efficiency of hospital healthcare services and procedures.                                                                                                                      

Assist s in the promotion and maintenance of high quality care through the analysis, review, and evaluation of clinical criteria as it relates to patient treatment and length of stay.

Able to read and interpret ICD10 and DSMV language.

Provides consultation for appropriateness of admission, continued stay, and discharge planning.

Maintains professional, open communication with insurance providers.

Able to successfully interpret physician documentation and effectively relay to insurance organizations.

Capable of effectively communicating with physician(s).

Communicates denials and peer-to-peer reviews clearly to physicians, business office, and the UR Director when necessary.

Manages, prepares, and submits appeals to third party payers.

Successfully monitors appeals and communicates results to business office, CFO, and UR Director as applicable.

Participates in monthly denial meetings.

Participates in UR Committee.

Communicates discharge information to insurance organizations in a timely manner.

Tracks and communicates utilizes MIDAS reports and excel spreadsheets UR data including but not limited to length of stay, underutilization, denial rates, and various other UR support data.

Sufficiently utilizes MIDAS software to track and update utilization status.

Effectively tracks denial information and communicates with UR Director and/or CFO/business office as needed.

Follows physician rationale for continued stay.

Prior authorizes new admissions according to contractual requirements.

Successfully audits documentation to support diagnosis.

Collaborates effectively with various departments of the hospital to ensure completion, accuracy of UR functions.

Maintains service excellence with all insurance providers, hospital staff, and physicians.

Collaborates with the department to build UR monthly reports.

Knowledgeable regarding CMS, TJC, and, state/local UR regulatory standards

Communicates effectively with UR Director on staffing/department needs.

Responsible for participating in monthly reporting requirements.

PROFESSIONAL REQUIREMENTS

Completes annual education requirements

Maintains regulatory requirements.

Maintains patient confidentiality requirements.

Attends annual review and performs department inservices.

Represents the organization in a positive profession manner.

Wears identification while on duty.

Reports to work on time and as scheduled.

Job Requirements

::

REGULATORY REQUIREMENTS:       RN, BSN, MSN, and/or Masters in a clinical field required.  One year of UR experience in a inpatient hospital setting preferred.  Must have knowledge of ICD10 and DSMV language.  Strong communication, documentation, clinical, and critical thinking skills essential.  Working knowledge of UR/case management preferred.  Ability to professionally communicate sensitive information to insurance organizations, hospital physicians, and hospital staff required.

LANGUAGE SKILLS

Ability to read and communicate effectively in English.

SKILLS

Computer knowledge.  Knowledge of clinical platforms such as Nuance, MIDAS, AS400, ect. Must be able to collaboratively work with physicians and effectively problem solve

MACHINES, TOOLS, AND EQUIPMENT USED ON THE JOB

Telephone, computer/printer, calculators, copy machine, shredder, keyboard, fax, file cabinets, and various computer software.

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