Utilization Review Coordinator, Behavioral Health in Norwalk, CA at Pipeline Health

Date Posted: 10/3/2022

Job Snapshot

  • Employee Type:
    Part-Time
  • Location:
    Norwalk, CA
  • Job Type:
  • Experience:
    Not Specified
  • Date Posted:
    10/3/2022

Job Description

Each day is a fresh opportunity to impact the lives of our patients, families, co-workers, and communities. We promote excellence, optimism, respect, and professional growth. If you are looking for a rewarding and positive workplace, look no further than in your own community

Position Summary:
The Utilization Review Coordinator will monitor adherence to the hospital's utilization review plan to ensure the effective and efficient use of hospital services and monitor the appropriateness of hospital admissions and extended hospitals stays. Perform various clerical tasks utilizing knowledge of office systems and procedures, facility regulations, and interdepartmental functions.

Responsibilities:

  • Demonstrates knowledge and skill set to process Medical TARS
  • Responsible for processing all TARS in BHU after patient discharges Including:-Confirms Medical TARS are completed for all dates of service and requests follow-up from the case managers, including clinical write up, as needed.-Prepare face sheets and print eligibility for patients. Coordinates with HIM to request necessary medical records. -Prints the complete medical record utilizing TAR report template in EMR. Assemble chart. Complete IS, complete TAR, and audit TAR to ensure TAR is accurately completed.-Submit Medical TAR to Medical field office via courier on designated days of workweek post discharge of patients
  • Prepares Medical appeal decisions involving upheld denied days for further appeal by providing Director of Case Management or Supervisor the original TAR, original adjudication response, appeal letter decision and face sheet for submission to contracted vendor to appeal further
  • Processes adjudication responses and appeal decisions from Medical, upon receipt to case management, to include date stamp the date received and log all cases decisions on Medical log
  • Completes data entry in Revenue Cycle of Cerner software to document TARS submission to MCal TAR Field office, TAR denials, and appeal submission to DMH. Maintaining documentation in appropriate queue in the Revenue cycle depending on status of account.
  • Monitors Medical case lists in Revenue Cycle on weekly basis, at least, to verify the status of TARS needed to be completed and status on TARS needing appeals and follows up to process timely
  • At the direction of Director of Case Management or Case Management Supervisor, compiles, maintains and disseminates Medical Denial statistical data and reports ( i.e. TAR denial and TAR summary reports) on weekly and monthly basis
  • Establishes and maintains efficient methods of ensuring the medical necessity and appropriateness of hospital admissions.
  • Performs concurrent reviews for patients to ensure that extended stays are medically justified and are so documented in patient medical records.
  • Coordinates and supervises the activities of the Utilization Review Department.
  • Calculates the lengths of stay and continued-stay days for patients.
  • Refers to the Utilization Review Physician Advisor cases that do not meet established guidelines for admission or continued stay.
  • Assists the Utilization Review Committee in the assessment and resolution of utilization review problems.
  • Identifies problems related to the quality of patient care and refers them to the Quality Assurance Committee.
  • Maintains communication with the Social Service Department to facilitate timely discharge planning.
  • Compiles monthly reports and statistics for presentation to the Utilization Review Committee.
  • Regularly attends required in-services and continuously takes an active interest in continuing learning
  • Exhibits behavior that is courteous, compassionate, polite, friendly, and respectful towards patients, visitors, physicians, and co-workers and extends self to make patients, visitors, clinical staff, and peers feel welcome and respected.

Qualifications:

  • Five years + experience in acute care hospital Utilization Review.
  • Current CPR BLS for healthcare provider’s card upon hire
  • Possesses skill set to provide clerical support to the Case Management Department.
  • Excellent verbal and written communication skills to interact appropriately with providers, other departments and vendors
  • Excellent organizational skills and attention to detail.
  • Excellent time management skills with a proven ability to meet deadlines.
  • Computer literate with ability to use Microsoft Office applications required.
  • Performs all job duties in a professional manner.
  • Bilingual (English/Spanish) preferred.

ADA CONSIDERATION: 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. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Such accommodations must be requested by the employee/applicant in order to be considered

LANGUAGE SKILLS: Must be able to read, analyze, and interpret common scientific and technical information, and to be easily understood through verbal communication in the English language. Must be able to prepare documentation in a manner that conforms to prescribed style and format, and to respond to common inquiries or complaints from customers, regulatory agencies, or members of the business community. Bilingual skills (Spanish) preferred.

MATHEMATICAL SKILLS: Must be able to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to perform these operations using units of weight measurement, volume, and distance. Ability to perform upper level mathematical operations, including algebra and geometry, frequent distribution, determination of test reliability and validity, analysis of variance, correlation techniques, sampling theory and factor analysis.

PHYSICAL DEMANDS: Is occasionally required to stand; walk; sit; use hands to finger, handle, or feel; reach with hands and arms; stoop, kneel, crouch, or crawl; talk or hear; and taste or smell. The employee is regularly required to lift, push and/or pull weights in excess of 10 pounds. The employee must occasionally lift and/or move more than 100 pounds, with assistance. Specific vision abilities required by this job include close vision, color vision, peripheral vision, depth perception, and ability to adjust focus.

WORK ENVIRONMENT: Is occasionally exposed to toxic or caustic chemicals, risk of electrical shock, and vibration. The noise level in the work environment is usually moderate.