LPN - LVN - UTILIZATION REVIEW COORDINATOR JOB
Company: Oceans Healthcare
Location: Shreveport
Posted on: February 22, 2021
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Job Description:
The Utilization Review Coordinator is responsible for management
of all utilization review and case management activities for the
facility's inpatient, partial hospitalization, and outpatient
programs. Conducts concurrent reviews of all medical records to
ensure criteria for admission and continued stay are met and
documented, and to ensure timely discharge planning. Coordinates
information between third party payers and medical/clinical staff
members. Interacts with members of the medical/clinical team to
provide a flow of communication and a medical record which
documents and supports level and intensity of service rendered. All
duties to be done in accordance with Joint Commission, Federal and
State regulations, Oceans' Mission, policies and procedures and
Performance Improvement Standards.Essential Functions:Identifies
and reports appropriate use, under-use, over-use and inefficient
use of services and resources to ensure high quality patient care
is provided in the least restrictive environment and in a
cost-effective manner.Conducts review of all inpatient, partial
hospitalization, and outpatient records as outlined in the
Utilization Review/Case Management plan to (1) determine
appropriateness and clinical necessity of admissions, continued
stay, and or rehabilitation, and discharge; (2) determine
timeliness of assessments and evaluations; i.e. H, psychiatric
evaluation, CIA formulation, and discharge summaries; and (3)
identify any under-, over-, and/or inefficient use of services or
resources.Reports findings to appropriate disciplines and/or
committees; notifies appropriate staff members of any deficiencies
noted so corrective actions can be taken in a timely manner;
submits monthly report to PI Coordinator of findings and actions
recommended to correct identified problems.Coordinates flow of
communication between physicians/staff and third party payers
concerning reimbursement requisitesAttends mini-treatment team and
morning status meetings each weekday to obtain third-party payer
pre-certification and ongoing certification requirements and to
share with those attending any pertinent data from third-party
payer contracts.Attends weekly treatment team.Conducts telephone
reviews to, and follows through with documentation requests from
third party payers.Maintains abstract with updates provided to
third party payers.Notifies physicians/staff/patients of
reimbursement issues.Initiates and completes appeals process for
reimbursement denials; notifies inpatients of denials
received.Reports monthly all Hospital Issued Notices of
Non-coverage (HINN letter) to QIO.Upon notification by business
office that potential exists to be included on a new managed care
contract, makes contact with the managed care company and
coordinates communications between administration and the managed
care company to obtain contractual arrangements. Maintains
coordination of information requests from third party payers for
annual renewal or update of existing contracts. Communicates to
staff status of new/existing contracts.Performs case management
duties as required and coordinates flow of communication among
staff involved in the patient's care.Completes paperwork for
judicial commitments and state bed packets.Completes referral
process and necessary paperwork for all other levels of care and
make follow-up appointments; including follow up letters needed by
the patient.Conducts special retrospective studies/audits when need
is determined by M and /or other committee structure.Performs other
duties and projects as assigned.Educational/Experience
Requirements:Associate's Degree with emphasis on healthcare or
Bachelor's degree in social services field preferred. At least one
year psychiatric/chemical dependency experience with good working
psychiatric/medical knowledge.Qualifications/Skills:Must have
excellent assertive communication skills. Knowledge and in-depth
understanding of CD-psych treatment and discharge planning process.
Must have good writing and composition skills. Must have good
understanding of regulatory and fiscal reimbursement and
utilization review as a primary component of patient care. Must
demonstrate strong patient advocacy skills. Must be able to
organize and prioritize high volume workload. Must be able to
analyze and utilize data and systems to provide individualized
quality treatment in a cost-effective manner. Must be able to
function with minimal supervision. Therapeutic Intervention
De-escalation Education required. Must have ability to maintain
overall good work attitude and interact cooperatively and
professionally with other staff members and third party payers to
achieve mutually beneficial outcome. Must possess basic competency
in age, disability, and cultural diversity for needs of patients
served and ability to relate to patients in a manner sensitive to
those needs. Must successfully complete CPR certification and an
Oceans approved behavioral health de-escalation program.
Keywords: Oceans Healthcare, Shreveport , LPN - LVN - UTILIZATION REVIEW COORDINATOR JOB, Healthcare , Shreveport, Louisiana
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