Utilization Review Coordination at AdventHealth

Date Posted: 7/2/2019

Job Snapshot

  • Job Schedule
    Full-Time
  • Location:
    Ottawa, KS
  • Job Category
  • Date Posted:
    7/2/2019
  • Job ID:
    19010418
  • Job Family
    Quality/Clinical Effectiveness
  • Travel
    No
  • Shift
    1 - Day
  • Application Zone
    1-Shared Services
  • Organization
    AdventHealth Ottawa

Job Description


Description

Utilization Review Coordinator AdventHealth Ottawa

Location Address: 1301 S. Main Street, Ottawa, KS 66067
Top Reasons To Work At AdventHealth Ottawa
  • Family friendly community
  • Excellent cost of living
  • Five major recreational lakes
  • Many annual events and festivals
  • Environment committed to patient care
 
Work Hours/Shift:
  • Full Time
 
You Will Be Responsible For:
  • Effectively functions as part of a self-directed work team
  • Coordinates the integration of utilization management, care coordination and discharge planning functions for patient care to meet established level of care, length of stay goals and patient needs, complying with all associated regulatory requirements and policies.

  • Anticipates discharge planning needs; refers discharge planning and psychosocial needs to Social Worker or other appropriate parties.

  • Communicates timely and effectively with third party payers regarding certification and discharge needs.

  • Maintains confidentiality of patient and business information

  • Documents appropriately and timely in the EMR as applicable

  • Assesses and refers appropriate cases to the Physician Advisor for review

  • Conducts initial, concurrent, and retro reviews as necessary for department productivity.  Conducts utilization review with external review agency representatives as required

  • Assesses appropriate level of service of assigned patients.  Informs and assists physicians to ensure appropriate documentation exists to support assigned level

  • Maintains knowledge and application of Evidence Based Criteria.  Able to identify and apply correct criteria to determine medical necessity and level of care

  • Demonstrates knowledge of regulatory guidelines and requirements for utilization management and discharge planning assessment as indicated by TMC, CMS, Livant and other agencies

  • Demonstrates proficiency in use of the electronic medical record and programs specific to the role

  • Cooperates with changes in staffing schedules and workload to achieve department productivity standard

  • Participates in Performance Improvement activities

  • Review patient medical record for over, under, and inappropriate utilization.  Review for justification of patient admission and continued stay.  Conducts timely and accurate interventions and follow-through

  • Tracks and documents avoidable days; proactively intervenes when appropriate and/or warranted

  • Utilizes criteria for referring patients for long stay reviews

  • Proactively manages and/or assists with addressing denials

  • Respond to Work items within a timely and detailed fashion

  • Track and trend denials making system improvements which may include working with a subgroup or committee

  • Provides feedback to staff and other departments as necessary regarding the trending of any issues identified and collaboratively works to develop action plans to improve the processes

  • Creates and reports relevant accurate, and timely reports concerning denials and appeals using spreadsheets, data and graphs as needed to applicable committees or leadership


Qualifications
What You Will Need:
  • Associate Degree in Nursing (BSN Preferred)  
  • 2 Years minimum experience in an Acute medical Hospital setting within the last 3 years OR 2 years minimum of Care Management Experience in an insurance company setting
  • Kansas Nursing License
  • CPR certification within one month of hire
  • Knowledge and Application of Evidence Based Criteria
  • Knowledge and Application of Regulatory Agency Requirements
Job Summary:

The UR Coordinator provides expertise for enhancing the quality of patient management and satisfaction, continuity of care and cost effective practices through effective and timely care coordination.  The UR Coordinator has accountability for care coordination, utilization review and discharge planning assessment.  The UR Coordinator performs varied duties relating to utilization management both concurrently and retrospectively, incorporating knowledge of hospital policies/procedures/protocols, state and federal regulations, and utilization criteria as established by the medical staff, and nursing/health care knowledge.  They communicate findings to appropriate parties as indicated to facilitate the utilization review process or quality improvement initiatives related to utilization management (e.g. external review organizations, medical/organizational departments or committees).  Additionally, works closely with social services and others to assure the patient moves efficiently through the continuum of care, focusing on minimizing system barriers for timely and safe patient discharge to the next appropriate level of care.  The UR Coordinator assesses readmissions and assists the quality management process in identifying trends and establishing plans of correction where appropriate.


This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.

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