Under the general supervision of the Regional Director of Utilization Review the Regional Utilization Review Coordinator is responsible for overseeing and coordinating the utilization review processes across multiple healthcare facilities within the region. This role ensures that patient care is delivered efficiently and effectively, while maintaining compliance with regulatory standards and optimizing resource utilization. Applies review criteria to determine medical necessity for admission and continued stay. Ensures the delivery of cost-effective quality healthcare and assists in the identification of appropriate utilization of resources across the continuum of care. This role involves working in a fast-paced environment with tight deadlines and changing priorities.

Works collaboratively with interdisciplinary staff internal and external to the organization.

1. Responsible for implementing the utilization management process for patients admitted to acute level of care.
2. Conducts concurrent clinical reviews for utilization/quality management activities, based on acute care guidelines/standards with focus on appropriateness of admission, monitoring length of stay, and discharge delays.
3. Provides appropriate reviews to multiple health plans/medical groups via agreed upon methods (telephone, fax, insurance portals).
4. Conduct and oversee utilization reviews to ensure appropriate use of medical services and resources. Evaluate patient care plans and medical records to determine the necessity and efficiency of services provided.
5. Provides retro review of identified cases denied by health plans for financial reimbursement.
6. Submits notification of admission and obtains timely authorizations for care from health plans, as needed.
7. Analyzes and identifies utilization patterns and trends of ancillary services as part of inpatient and observation visits and participates in the collection and analysis of data for the denial process as well as special studies, projects, audits, routine utilization monitoring activities.
8. Works under the guidance of and in collaboration with the hospital utilization review committee to maintain appropriate standards of utilization review and support the implementation of the hospital utilization review plan
9. Ensure compliance with all federal, state, and local regulations, as well as organization policies and procedures. Maintains Up to date knowledge of regulatory agency guidelines as they pertain to area of practice.
10. Functions as key resource provider related to utilization review, delivery of care, and effects of reimbursement on both patients and health care system.
11. Identifies avoidable delays or days/ assists in the collection of data to trend and analyze outcomes for identification of improvement opportunities.
12. Maintain work standards that are in compliance with ARH’s policies and governmental regulations and various regulatory agency requirements.
13. Work closely with healthcare providers, case managers, and other stakeholders to facilitate effective communication and coordination of care. Collaborate with the System Director of Case Management and other regional coordinators to develop and implement best practices.
14. Consistently maintains a professional commitment to institutions and department’s goals and objectives. Demonstrate flexibility to the department’s needs in relation to floor and work schedule and any other internal and external demands on the department. Continually shows commitment to the department by extending oneself when the need arises.
15. Attends and/or completes all required safety training programs and can describe his or her responsibilities related to general safety, department/service safety, and specific job-related hazards.
16. Demonstrates respect and regard for the dignity of all patients, families, visitors, and fellow employees to ensure a professional, responsible, and courteous environment.

Minimum Education
LPN or RN graduated from an accredited school of nursing with a state license to practice professional nursing in state of resident facility. BSN preferred.
Previous experience in the area of utilization review and/or case management preferred.
Working knowledge of federal, state, and regulatory requirements in quality assessment, case management, resource management, hospital systems, accreditation, and licensure strongly preferred

Willing to obtain licensure in additional states, as needed

Minimum Work Experience
Minimum of three years of acute care hospital experience required.
Demonstrated skills in the areas of negotiation, communication (verbal and written), conflict, interdisciplinary collaboration, management, creative problem solving, and critical thinking. Knowledge of healthcare financing, community and organizational resources, patient care processes, and data analysis.
Knowledge of utilization management as it relates to third-party payers.
Experience with managed care is preferred. Excellent verbal and written communication skills required.
Demonstrates flexibility via an ability to adapt to changing priorities and regulations.
Basic computer skills required.

Required Licenses/Certifications
• CPR certification to be obtained within 30 days of hire.
Certification in Utilization Review (e.g. CPHQ, CCM) preferred.

Required Skills, Knowledge, and Abilities
• Chart review and good working clinical knowledge base with excellent communication skills necessary to interact with physicians and medical staff.
• General idea of governmental and private insurance guidelines.