Utilization Review & Payer Liaison

Oceans Healthcare, L.L.C.; Baton Rouge (LA); On-site; USD 65,000 - 90,000; Full time

Job summary

Oceans Healthcare, L.L.C. in Baton Rouge, LA, seeks an Utilization Review Coordinator to oversee inpatient, partial hospitalization, and outpatient review activities.

The role ensures admission and continued stay criteria are documented and discharge planning is timely, supporting high-quality patient care under Joint Commission and state regulations. You will coordinate information between third-party payers and medical staff, attend daily and weekly leadership meetings, manage

Responsibilities

• Identifies and reports appropriate use, under-use, over-use and inefficient use of services and resources to ensure high quality patient care is provided in the least restrictive environment and in a cost-effective manner.
• Conducts review of all inpatient, partial hospitalization, and outpatient records as outlined in the Utilization Review/Case Management plan to determine appropriateness and clinical necessity of admissions, continued stay, and discharge; determine timeliness of assessments and evaluations (H&Ps, psychiatric evaluation, CIA formulation, discharge summaries).
• Reports findings to appropriate disciplines and/or committees; notifies appropriate staff of deficiencies; submits monthly report to PI Coordinator with actions to correct identified problems.
• Coordinates flow of communication between physicians/staff and third party payers concerning reimbursement requisites.
• Attends mini-treatment team and morning status meetings each weekday to obtain third-party payer pre-certification and ongoing certification requirements and to share pertinent data from third-party payer contracts.
• Attends weekly treatment team; conducts telephone reviews to and follows through with documentation requests from third party payers; maintains abstract with updates provided to third party payers; notifies physicians/staff/patients of reimbursement issues; initiates and completes appeals process for reimbursement denials; reports monthly all HINN notices to QIO.

Job description

Oceans Healthcare, L.L.C. in Baton Rouge, LA, seeks an Utilization Review Coordinator to oversee inpatient, partial hospitalization, and outpatient review activities.

The role ensures admission and continued stay criteria are documented and discharge planning is timely, supporting high-quality patient care under Joint Commission and state regulations. You will coordinate information between third-party payers and medical staff, attend daily and weekly leadership meetings, manage