Coordinator-UtilizationMgt​/Rvw. Children's Hospital

Job Summary

Job Summary: The Coordinator-Utilization Management and Review is responsible for the support of the daily function and operations of the Case Manager and Discharge Planner related to the utilization management and/or discharge planning: review medical records for medical necessity of admission, treatment, and initial referrals for Government Programs, interfaces with payers to extend authorization for treatment, collaborates with PBO (Patient Business Office) for identification of payer sources, eligibility, or indigent programs, completes TARs (Treatment Authorization Requests) for submission to the county field offices for medical authorization, supports medical on-site reviewer functions, assist with reimbursement and authorization according to contracts, coordinates and supports the denials and appeals process.

Is able to function under the direction of a Case Manager and Discharge Planner with minimal supervision, takes responsibility for professional growth, and assists in the management of patient placements and ordering of durable medical equipment and coordinating discharge. Performs other duties as needed.

Education and Experience: High School Diploma or GED required. Associate s Degree preferred. Minimum three years of experience with a medical group, managed care organization, utilization management, hospital admitting or medical nursing unit required.

Knowledge and

Skills:

Acquires and maintains a working knowledge of Medi-Cal, CCS, Healthy Families, commercial regulations, and managed care. Knowledge of state managed health plans and contracting preferred. Able to read; write legibly; use computer, printer, and software programs necessary to the position. Able to relate and communicate positively, effectively, and professionally with others; be assertive and consistent in following and/or enforcing policies;

work calmly and respond courteously when under pressure; lead, supervise, teach, and collaborate; accept direction. Able to communicate effectively in English in person, in writing, and on the telephone; think critically; work independently with minimal supervision; perform basic math functions; manage multiple assignments effectively; work well under pressure; problem solve; organize and prioritize workload; recall information with accuracy; pay close attention to detail.

Able to distinguish colors and smells as necessary for patient care; hear sufficiently for general conversation in person and on the telephone; identify and distinguish various sounds associated with the work place/patient care; see adequately to read computer screens, medical records, and written documents necessary to position; discern temperature variances through touch.

Licensures and

Certifications:

Nationally recognized certification in Utilization Management, Utilization review, Hospital Utilization review, Managed Care, or healthcare related required within two years of hire date. Current cardiopulmonary resuscitation (CPR) certificate required.