Utilization Review Coordinator

About the position

The Utilization Review Coordinator at Wills Eye Hospital plays a critical role in managing inpatient care through utilization review, chart surveillance, and denials management. This position requires collaboration with medical teams and payers to ensure patients receive appropriate care based on established guidelines. The coordinator will assess clinical needs, determine insurance coverage, and facilitate the utilization review process, ensuring compliance with medical necessity criteria.

Responsibilities
? Obtain necessary information to assess a patient's clinical condition and ongoing care needs.
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? Determine patient's insurance coverage and eligibility for the utilization review process.
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? Use MCG guidelines to establish medical necessity and determine inpatient versus observation status.
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? Utilize clinical skills for utilization review, continued stay reviews, and management of inpatient cases.
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? Review assigned ICD-10 codes and CPT codes for appropriate reimbursement.
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? Review prior authorization/observation stay requests to determine appropriate care and setting.
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? Ensure accuracy and completeness of inpatient Amkai chart records and monitor trends of inappropriate resource utilization.
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? Collaborate with staff within the provider's network and serve as a resource regarding authorization policies and treatment options.
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? Stay current on clinical practices and protocols affecting clinical reimbursement.
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? Participate in meetings and committees related to the role and represent the department as necessary.
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? Collaborate with billing office staff to review denied claims and assist with the appeals process.
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? Perform other related duties as assigned.

Requirements
? Bachelor's of Nursing Degree or equivalent required.
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? Active Pennsylvania State Nursing License required.
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? Basic Life Support (BLS) Certification required.
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? Minimum of 2 years' experience as a clinical nurse in an acute care/hospital setting.
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? Experience with Prior Authorization and Utilization Review.
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? Experience using Milliman or InterQual criteria for medical necessity and patient management.
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? Organized, detail-oriented, and capable of handling multiple issues.

Nice-to-haves

Benefits

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