The Utilization Review Coordinator is responsible for evaluating admission data and assigning length of stay and anticipated date of discharge for patients admitted to the hospital to assure compliance with federal and state regulations and accrediting agencies.
ResponsibilitiesReview physician admitting documentation and assign diagnosis and specified length of stay. Refers questionable cases to Physician Advisor.
Review medical record documentation and in conjunction with utilization review committee ascertains if extension of length of stay is justified.
Review patients' records to ascertain if appropriate type and quality of care was given according to established criteria.
Observe the use of ancillary services and identify the under and/or over utilization of these services.
Review charts of patients who have a change of status to assure that necessary payment status is changed.
Review PSRO sheets to assure correct coding and forwards sheets to Medical Records.
Contact attending physician for additional information and provide information to review committee to expedite this review of charts.
Prepare on a timely basis and maintains records, forms, and reports required by the hospital, and regulatory agencies.
Provide necessary information to various hospital departments to use in preparation for a survey by third party payors and other agencies.
Recommend for approval by state regulatory agencies changes in criteria and standards.
Perform other related duties within the scope of the job classification.
QualificationsEDUCATION, TRAINING REQUIREMENT:
Graduate from an accredited School of Nursing with current licensure in state of employment,
OR
completion of two (2) years accredited Records Technician Program with two (2) years experience or completion of an accredited program and current credentialing in a health related field.
Possess a high degree of clinical, medical, and nursing competence with ability to make appropriate professional judgement.
Possess a high degree of skill in human relations with ability to deal constructively on a one-to-one basis with physicians, nursing staff, department heads, administrative personnel, medical records personnel, patients, and representatives of government or third party agencies.
SPECIFIC ACCOUNTABILITIES:
Responsible for the proper coordination and implementation of the entire Utilization Review Process.
Responsible for maintaining accurate files, giving accurate patient information to the physician and the third party payors and assures proper documentation on the medical record of the patient to justify current course of treatment and care.
Responsible for preparing various reports to medical committees and to hospital administration and third party payors.
Responsible for accomplishment of specific work assignments as directed by the Chairman of the Utilization Review Committee and department head.