Medical Review Coordinator II

Prime Healthcare; Evanston (IL); On-site; USD 48,000 - 69,000; Full time

Job summary

Prime Healthcare St Francis Hospital in Evanston, IL seeks a full-time Utilization Management professional to coordinate clinical reviews, work with the CMO, and support case management with data-driven decisions.

The candidate will review patient charts for admission and ongoing treatment criteria, gather data for payer requests, and coordinate discharge referrals while maintaining independence and sound judgment.

Qualifications

• Requires degree in medical field (MD/DO, dental, PA, or nursing).
• Two years Utilization Review experience as Medical Review Coordinator I.
• Knowledge of clinical pathophysiology and pharmacology.

Responsibilities

• Coordinate and complete clinical reviews for patient medical records with the CMO.
• Participate in Case management and UR meetings.
• Educate departments on utilization review processes.
• Review patient charts to assess admission/continuation criteria; gather data and respond to requests for records.
• Coordinate discharge referrals as requested by clinical staff, payers, patients and families.
• Work independently with sound judgment.
• Knowledge of federal, state and intermediary guidelines for inpatient and other levels of care.

Skills

Communication skills

Critical thinking

Interpersonal skills

Independent work

Typing speed 35 wpm

Education

Medical/Dental/PA/Nursing degree

US health-related bachelor's degree

MPH or related graduate degree

Job description

Overview

• Description: Utilization Management
• Schedule: Full Time 8a-4:30p
• Facility: Prime Healthcare St Francis Hospital
• Location: Evanston, IL

Responsibilities

Coordinates and completes the clinical reviews for all patient medical records while working closely with CMO (Chief Medical Officer). Actively participates in the Case management and UR meetings. Serves as on-going educator to all departments. Responsible for reviewing patient charts in order to assess whether the clinical criteria for admission and continuation of treatment is being met; gathering data and responding to request for records from payers/fiscal intermediary etc.; gathering clinical and fiscal information and communicating status of both open and closed accounts for multiple levels of Utilization Review and Case Management reporting. Able to work independently and use sound judgment. Knowledge of Federal, State, and intermediary guidelines related to inpatient, acute care hospitalization, as well as lower levels of care for the continuity of treatment. Coordinates discharge referrals as requested by clinical staff, fiscal intermediary, patients, and families. Performs other duties as assigned.

Qualifications

EDUCATION, EXPERIENCE, TRAINING

Required qualifications:

1. Medical Graduate, Dental Graduate, PA, or Nursing Graduate required.
2. Two years of Utilization Review experience as a Medical Review Coordinator – I required.
3. Knowledge of Clinical Pathophysiology and Pharmacology required.

Preferred qualifications:

1. ECFMG Certification And/or Bachelor’s or higher from a US-based accredited institution in a Health and Human Services field is highly preferred.
2. Master of Public Health (MPH) or post-graduation in a related health care field preferred.
3. Clinical experience in acute care setting preferred.
4. Excellent written and verbal communication skills. Excellent critical thinking skills.
5. Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff, coding staff and hospital management staff.
6. Ability to work independently in a time-oriented environment.
7. Computer data entry with 10-key preferred, with accurate typing speed of 35 wpm preferred.

Pay Transparency

Saint Francis Hospital offers competitive compensation and a comprehensive benefits package that provides employees the flexibility to tailor benefits according to their individual needs. Our Total Rewards package includes, but is not limited to, paid time off, a 401K retirement plan, medical, dental, and vision coverage, tuition reimbursement, and many more voluntary benefit options. A reasonable compensation estimate for this role, which includes estimated wages, benefits, and other forms of compensation, is $34.65 to $50.18. The exact starting compensation to be offered will be determined at the time of selecting an applicant for hire, in which a wide range of factors will be considered, including but not limited to, skillset, years of applicable experience, education, credentials and licensure.

The company is dedicated to empowering its staff with a comprehensive, competitive benefits package, allowing them the freedom to customize their benefits to fit their unique needs. Our abundant resources, programs, and voluntary options serve as a foundation for individual growth and well-being. Learn more here: https://www.primehealthcare.com/benefitsthatmattermost/

Employment Status

Full Time

Shift

Days

Equal Employment Opportunity

Company is an equal employment opportunity employer. Company prohibits discrimination against any applicant or employee based on race, color, sex, sexual orientation, gender identity, religion, national origin, age (subject to applicable law), disability, military status, genetic information or any other basis protected by applicable federal, state, or local laws. The Company also prohibits harassment of applicants or employees based on any of these protected categories. Know Your Rights: https://www.eeoc.gov/sites/default/files/2022-10/EEOC_KnowYourRights_screen_reader_10_20.pdf