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Utilization Review Coordinator

2 months ago

Elkridge, Maryland, United States Sheppard Pratt Full time
Job Summary

We are seeking a highly skilled Utilization Review Coordinator to join our team at Sheppard Pratt. This role is responsible for reviewing and assessing the appropriateness of patient admissions and continued stays, working with financial case management representatives to optimize insurance benefits, and providing timely and pertinent insurance benefits information to clinical staff.

Key Responsibilities
  • Utilization Review: Conduct thorough reviews of patient medical records to determine the necessity and appropriateness of hospital stays, working closely with physicians and other healthcare professionals to ensure that patients receive the most effective and efficient care.
  • Insurance Benefits Management: Collaborate with financial case management representatives to monitor and maximize the use of insurance benefits, ensuring that patients receive the best possible care within their benefits package.
  • Clinical Support: Provide timely and pertinent insurance benefits information to clinical staff, enabling them to provide care that is aligned with patients' benefits packages and optimizing third-party payment for services.
  • Appeals and Hearings: Assist physicians in preparing appeals when payment has been denied by insurance companies, and represent the hospital in involuntary hearings processes.
  • Committee Support: Serve as a member of various clinical committees, providing staff support to committee chairpersons and contributing to the development and implementation of hospital utilization review plans.
Requirements
  • Education: Bachelor's degree from an accredited institution in nursing, allied health, records administration, or a closely related field.
  • Experience: Two to three years of related experience in utilization review, case management, or a related field, with comprehensive knowledge of patient medical records, health insurance provisions, psychiatric diagnoses, and utilization review practices.