Utilization Review Coordinator

The Utilization Review Coordinator 2 reviews medical records of clients who are receiving treatment for mental illness to ensure proper utilization of treatment resources. The position reviews client records for proper case documentation and medical necessity of treatment in relation to federal, state, contractual, and county regulations. Reviews and assesses continuing treatment plans, and advocates for required treatment with appropriate service providers.

This position differs from professional clinical positions in that the Utilization Review Coordinator 2 reviews client records rather than provides services to clients. The position is distinguished from higher-level manager or director positions in that it does not directly supervise clinicians. The position report’s findings to Supervisors, Managers, and Executive Leadership. Makes clinical and administrative recommendations, determines financial eligibility for state funds, and provides information to external auditors in clinical and administrative review and certification checks.

The following examples of duties and accountabilities illustrate the general range of tasks assigned to the position but are not intended to define the limits of required duties. Other essential duties may be assigned consistent with the general scope of the position. Employee must comply with all County and department policies, procedures, WACs, or other regulatory bodies.

• Reviews client enrollment data and clinical documentation to ensure compliance with federal, state, contractual, and county regulations relating to medical necessity and case documentation.
• May interview clients and consult with clinical staff for additional information.
• Consults with medical and clinical staff regarding patient diagnosis, service justification, length of treatment and case documentation.
• Assesses records for appropriate level of care and treatment, aftercare, and discharge planning for clients. Ensures proper utilization of treatment resources, compliance with regulations and fidelity to program model and service philosophies. Completes clinical chart reviews as required per WAC.
• Advocates for required patient treatment with providers.
• Determines clinical and charting compliance using auditing tools, issues findings, and makes recommendations for change to Supervisors, Managers, and/or Executive Leadership. Follows up on recommendations to determine compliance with findings.
• Provides training and information about utilization requirements to clinical, supervisory, and management staff.
• Conducts evaluations and assessments of current practices to identify treatment alternatives and strategies for the delivery of programs and individualized services.
• Monitors programs and services in order to ensure that desired changes are affected, objectives achieved, and program changes are maintained.
• Works with HIPAA Officers in monitoring the performance of the Compliance Program and related activities on a continuing basis. Takes appropriate steps to improve its effectiveness.
• Documents outcomes following changes to determine efficacy.
• Evaluates new regulations and makes recommendations for departmental compliance.
• Participates with departmental staff in utilization and quality improvement meetings and projects.
• Gathers data, prepares reports, and conducts studies and research on utilization review and quality issues.
• Participates in audits of programs to ensure agency compliance on utilization review regulations.
• Provides clinical training to mental health staff as needed by the department.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Any combination of education and experience may be substituted as long as it provides the desired skills, knowledge, and abilities to perform the essential functions of the job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Required