Utilization Management Coordinator

Responsibilities

The UM Coordinator contacts external case managers/managed care organizations for certification and recertification of insurance benefits throughout the patients stay, and assists the treatment team in understanding the insurance companys requirements for continued stay and discharge planning.

The UM Coordinator is responsible for having a thorough understanding of the patients treatment through communication with the treatment team.

The UM Coordinator advocates for the patients access to services during treatment team meetings and through individual physician contact.

Review the treatment plan and advocate for additional services as indicated.

Promote effective use of resources for patients.

Ensure that patient rights are upheld.

Maintain ongoing contact with the physician, program manager, nurse manager, and various members of the team.

Collaborate with the treatment team regarding continued stay and discharge planning issues.

Advocate that the patient is placed in the appropriate level of care and program.

Interface with program staff to facilitate a smooth transition at the time of transfer or discharge.

Maintain documentation related to UR activities Assure tracking of insurance reviews, and that reviews are completed in a timely manner.

Maintain statistical reports and prepare documentation of significant findings.

Communicate insurance requirements to all levels of staff.

Provide timely updates regarding patient status on log sheets that are prepared for daily meetings concerning admissions, reviews, and discharges. Update the denial log statistics on an ongoing basis (at least weekly), and initiate appeals through telephone or written communication within 7 to 10 days of denial.

Consult with the business office and/or admission staff as needed to clarify data and ensure the insurance precertification process is complete.

Provide clinical information to managed care companies, insurance companies and other third party reviewers to establish the length of stay or number of certified days.

Coordinate with the insurance company doctor in appeals process and denials process.

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We believe that diversity and inclusion among our teammates is critical to our success.

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Experience:

A minimum of two (2) years experience in a healthcare setting or managed care company, preferred Hospital experience. Bachelors degree with Masters preferred.