Utilization Review Coordinator Utilization Review Coordinator Arcata, CA

TimeTrex (TimeTrex Software Inc.); Arcata (CA); On-site; USD 85,000 - 115,000; Full time

Job summary

Mad River Community Hospital is seeking an Utilization Review Coordinator to join our dedicated team. You will facilitate utilization review activities in an inpatient setting and support discharge planning and transitional care for patients of our hospital.

You will collaborate with health plans and care teams to ensure appropriate resource use and timely discharge, conducting clinical reviews for services requiring authorization and communicating with insurers for approvals.

Qualifications

• Bachelor's or Master's degree in Nursing, Social Work, Sociology, or related field.
• Current clinical licensure, ideally RN or LCSW.
• Two to five years of acute care clinical experience.
• Working knowledge of DRG classification, CPT coding, and InterQual.

Responsibilities

• Collaborates with health plans and care teams to optimize resource use and timely discharge.
• Provides clinical review for services requiring authorization (acute inpatient, SNF, rehab, home health).
• Communicates with insurance representatives to ensure appropriate authorization for care.
• Develops discharge and transitional care plans based on patient and social needs assessment.
• Articulates legal issues related to patient care and issues denial letters per procedures.

Skills

RN/LCSW licensure

Clinical communication

DRG knowledge

CPT coding

InterQual knowledge

Education

Bachelor's or Master's degree in Nursing or Social Work

Tools

EMR systems

Job description

Mad River Community Hospital offers a friendly, family-oriented and welcoming workplace with excellent benefits. Come join our family of dedicated professional staff, where you can take pride in being a part of an exceptional team!

Utilization Review Coordinator reports to the Chief People and Compliance Officer.

The Utilization Review Coordinator is responsible for facilitating, coordinating, integrating and evaluating utilization review activities within the in-patient acute care setting. The UR Coordinator is part of a team that is accountable for facilitating and providing care coordination services and quality outcomes for patients through discharge planning and transitional care.

Responsibilities

• Collaborates and coordinates with health plans and providers/care teams to ensure appropriate utilization of resources and timely discharge.
• Provides clinical review for different healthcare services requiring authorization, including acute inpatient, skilled nursing facility, acute rehab, and home nursing.
• Communicates with insurance representatives and third party payers to ensure appropriate authorization for care.
• Collaborates and communicates with the care team to develop comprehensive discharge/transitional care plans based on assessment of the patient’s clinical and social needs.
• Demonstrates awareness and ability to articulate legal issues pertaining to patient and families, especially related to non-covered stay. Issues denial letters as appropriate following approved procedures.

Position Qualifications

• Bachelor or Master's degree in Nursing, Social Work, Sociology, or related field from an accredited school.
• Current clinical licensure, either Registered Nurse or Licensed Clinical Social Worker, preferred.
• Previous experience in utilization management, case management, discharge planning and/or home health or rehab preferred.
• Two to five years of recent acute care clinical experience.
• Working knowledge of DRG classification system, CPT coding, and INTERQUAL.
• Excellent written and verbal communication skills with the ability to interact with patients/family, clinical staff, insurance providers and post-acute care providers.
• Capable experience in using electronic medical records …
• Basic proficiency with MS Office …
• Current BLS certificate.

Equal Opportunity Employer

Mad River Community Hospital provides equal employment opportunities to all employees and applicants for employment without regard to race, color, religion, national origin, age, sex, sexual orientation, gender identity, disability or genetics. In addition to federal law requirements, Mad River Community Hospital complies with applicable state and local laws governing nondiscrimination in employment. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff and recall, and transfer ….