Utilization Review Coordinator (8 AM - 5 PM)

VieMed Healthcare; Lafayette (LA); In loco; USD 60.000 - 80.000; Tempo pieno

Descrizione del lavoro

VieMed Healthcare seeks a Registered Nurse reviewer in Lafayette, LA to conduct clinical chart reviews for therapies, equipment, and payer documentation. You will assess medical records, determine completeness, and communicate deficiencies to providers and intake leadership.

Solid nursing judgment and accuracy are essential as you ensure compliance with Medicare/Medicaid and commercial payer requirements, while maintaining timely documentation in the EMR system.

Competenze

• Current, active RN license in good standing.
• Clinical nursing experience with ability to review medical records and apply professional nursing judgement.
• Ability to read and interpret diagnoses, physician orders, progress notes, and other clinical records.
• Working knowledge of medical terminology and respiratory and DME therapies.
• Understanding Medicare, Medicaid, and commercial payer documentation requirements.
• Strong attention to detail with the ability to identify gaps and communicate clearly.
• Effective written and verbal communication with physicians, insurers, teams.
• Ability to manage multiple chart reviews and meet turnaround expectations.
• Proficiency with EMR, patient/referral databases, and MS Office.
• Demonstrated professionalism, initiative, and consistency in productivity.
• Availability Monday–Friday with potential weekends/overtime as needed.

Mansioni

• Conduct clinical reviews of patient medical records and referral documentation to evaluate documentation supports therapies, equipment, and coverage requirements.
• Review physician orders, progress notes, histories and physicals, diagnostics, test results, and hospital records relevant to referrals.
• Identify missing or unclear documentation and communicate deficiencies.
• Apply nursing knowledge to evaluate diagnoses, symptoms, and medical-necessity indicators.
• Provide recommendations on referral readiness and next steps based on chart reviews.
• Evaluate documentation against Medicare, Medicaid and commercial payer criteria prior to submission for reimbursement.
• Maintain compliance with governmental regulations and VieMed procedures.
• Accurately document findings, deficiencies, recommendations, and status in the system.
• Escalate complex questions to Intake Manager or leadership as needed.
• Perform other responsibilities and projects as assigned.

Conoscenze

RN license

Clinical nursing experience

Nursing judgement

Attention to detail

Verbal & written communication

Time management

Independent work

Team collaboration

Strumenti

EMR systems

Microsoft Office (Outlook, Word, Excel)

Descrizione del lavoro

Essential Duties and Responsibilities

Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions of this position.

• Conduct clinical reviews of patient medical records and referral documentation to evaluate whether documentation supports prescribed therapies, ordered equipment, supplies, and applicable coverage requirements
• Review physician orders, progress notes, histories and physicals, diagnostic information, test results, hospital records, and other relevant clinical documentation relevant to the referral
• Identify missing, incomplete, inconsistent, or unclear clinical documentation and communicate specific documentation deficiencies or clarification needs to the appropriate parties.
• Apply professional nursing knowledge when evaluating diagnoses, symptoms, treatment history, medical-necessity indicators, and the relationship between documented clinical findings and the requested therapy or equipment
• Provide recommendations regarding referral readiness, additional documentation requirements, and appropriate next steps based on clinical chart-review findings.
• Evaluate clinical documentation against applicable Medicare, Medicaid and commercial payer coverage criteria prior to submission for reimbursement or
• Maintain compliance with applicable governmental regulations, payer requirements and VieMed Intake, Billing and Compliance procedures
• Accurately document clinical review findings, identified deficiencies, recommendations, and referral status within the designated computer system
• Escalate complex clinical questions, documentation concerns, potential compliance issues and other matters requiring additional review to the Intake Manager, Intake Supervisor or appropriate leadership position
• Perform other responsibilities and projects assigned

Essential Duties and Responsibilities

Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions of this position.

• Conduct clinical reviews of patient medical records and referral documentation to evaluate whether documentation supports prescribed therapies, ordered equipment, supplies, and applicable coverage requirements
• Review physician orders, progress notes, histories and physicals, diagnostic information, test results, hospital records, and other relevant clinical documentation relevant to the referral
• Identify missing, incomplete, inconsistent, or unclear clinical documentation and communicate specific documentation deficiencies or clarification needs to the appropriate parties.
• Apply professional nursing knowledge when evaluating diagnoses, symptoms, treatment history, medical-necessity indicators, and the relationship between documented clinical findings and the requested therapy or equipment
• Provide recommendations regarding referral readiness, additional documentation requirements, and appropriate next steps based on clinical chart-review findings.
• Evaluate clinical documentation against applicable Medicare, Medicaid and commercial payer coverage criteria prior to submission for reimbursement or
• Maintain compliance with applicable governmental regulations, payer requirements and VieMed Intake, Billing and Compliance procedures
• Accurately document clinical review findings, identified deficiencies, recommendations, and referral status within the designated computer system
• Escalate complex clinical questions, documentation concerns, potential compliance issues and other matters requiring additional review to the Intake Manager, Intake Supervisor or appropriate leadership position
• Perform other responsibilities and projects assigned

Qualifications

• Current, active Registered Nurse (RN) license in good standing
• Clinical nursing experience with demonstrated ability to review medical records, interpret physician documentation, and apply professional nursing judgement.
• Ability to apply nursing knowledge and sound clinical judgment when evaluating the completeness and clinical relevance of medical documentation
• Ability to read and interpret diagnoses, physician orders, progress notes, diagnostic testing, treatment plans, and other clinical records
• Working knowledge of medical terminology and common respiratory and DME therapies
• Understanding medical insurance concepts and the ability to learn and apply Medicare, Medicaid, and commercial-payer documentation requirements
• Strong attention to detail with the ability to identify incomplete, conflicting, or insufficient documentation and communicate the specific gap clearly
• Effective written and verbal communication skills, including professional communication with physicians, healthcare providers, insurers, patients, colleagues, and leadership
• Ability to manage multiple chart reviews, prioritize workload, meet established turnaround expectations, and maintain accurate documentation
• Ability to work independently, exercise sound clinical judgement, while collaborating effectively across operational departments
• Proficiency with electronic medical records, patient/referral databases, and Microsoft Office applications, including Outlook, Word, and Excel
• Proficiency with electronic medical records, patient and referral databases, and Microsoft Office applications, including Outlook, Word, and Excel
• Demonstrated professionalism, accountability, , initiative, and consistent productivity
• Availability to work Monday through Friday during an agreed-upon shift. Weekend work, overtime, or on-call coverage may be required based on business needs

Access to Protected Health Information (PHI)

• This position requires the employee to handle Protected Health Information (PHI) for duties related to document and report preparation. Policies and procedures must be strictly followed to protect PHI as required by the HIPAA Privacy Rule.

Working Conditions

• This position will work in an office environment.

Normal business hours are Monday through Friday, 8:00 a.m. to 5:00 p.m.

This job description is not designed to cover or contain a comprehensive listing of all activities, duties, or responsibilities required of the employee. Essential duties and responsibilities may change at any time, with or without notice.

We are an equal opportunity employer and all qualified applicants will receive consideration without regard to their race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other characteristic protected by law.