Utilization Management Coordinator

3 weeks ago

Neptune City, United States Hackensack Meridian Health Full time

Overview:

Our team members are the heart of what makes us better.

At Hackensack Meridian Health we help our patients live better, healthier lives and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, competitive benefits are just the beginning. Its also about how we support one another and how we show up for our community.

Together, we keep getting better - advancing our mission to transform healthcare and serve as a leader of positive change.

The Utilization Management Coordinator coordinates and monitors daily activities of the utilization management functions of the Care Coordination Department, ensuring the appropriate allocation of hospital resources while maintaining quality of patient care. This position also holds the responsibility for ensuring regulatory compliance requirements and coordinating the medical management aspects of clinical review requests from external entities. The Utilization Management Coordinator serves as a functional expert and liaison to Care Coordinator Staff and other departments within the hospital system. The UM Coordinator assists to develop consistent processes and enhance workflow of the concurrent review process with third party payers. The UM Coordinator oversees and facilitates medical necessity appeals as the result of concurrent denials. The UM Coordinator functions as the PRO Liaison facilitating the review process for Hospital Issued Notices of Non-Coverage (HINN's) and discharge reviews as they relate to Care Coordinator activities and directing PRO correspondence and cost outliers to the appropriate internal department. Provides Care Coordination Support as needed.

Responsibilities:

A day in the life of a Utilization Management Coordinator at Hackensack Meridian Health includes:

  • Admission Classification: Coordinates with the admitting office to avoid inappropriate admissions.
  • Documentation: Documents/computer entry on medical records according to Department and Hospital Standards.
  • Education: Educates, trains, and serves as a resource person for the Care Management team, medical staff, residents, and other hospital staff on current utilization review methodologies, requirements and criteria.
  • Meetings and Committee Participation: Participates actively on appropriate committee, workgroup, and/or meetings. Is a positive problem solver. Identifies and refers quality issues for review to the Quality Management Program.
  • Physician Documentation: Prompts or queries physicians verbally and/or in writing for documentation accuracy to support medical necessity, patient acuity, complications and comorbidities.
  • Resource Management: Monitors and assesses the use of hospital services by administering utilization review procedures required under Federal, State and County regulations. Following guidelines established in the medical facility's Utilization Review plan.
  • Reviews: Admission Review; Admission Denial; Continued Stay Review; Continued Stay Denial; Termination of Benefits; Communication of Information to Insurance Company; Billing Certification for Medicaid; Concurrent Managed Care; Denial Appeals, etc.
  • Utilization Management: Provides concurrent and retrospective clinical information to the insurance company in accordance with contract provisions or within 24 hours or first business day of admission or request. Refers days for appeal to the physician advisor upon notification. Documents identified avoidable, denied, and alternate level of care days appropriately. Documents physician advisor's response to referral, final determination and certification of hospital days.
  • Other duties and/or projects as assigned.
  • Adheres to HMH Organizational competencies and standards of behavior.


Qualifications:

Education, Knowledge, Skills and Abilities Required:

  • Associate's Degree in Nursing.
  • A minimum of three years of acute care nursing experience.
  • Knowledge of health care delivery system, utilization review and case review procedures.
  • Excellent written and verbal communication skills.
  • Proficient computer skills that include but are not limited to Microsoft Office and/or Google Suite platforms.

Education, Knowledge, Skills and Abilities Preferred:

  • Bachelor's Degree in Nursing (BSN).
  • Experience working in a behavioral health setting.
  • Previous case management/utilization review experience.
  • Knowledge of Milliman Care Guidelines or Interqual.

Licenses and Certifications Required:

  • NJ State Professional Registered Nurse License.
  • AHA Basic Health Care Life Support HCP Certification.
  • Certification in Case Management, or eligibility in 3 years.

If you feel that the above description speaks directly to your strengths and capabilities, then please apply today

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