Schedule: Full-time day shift. Monday-Friday hours.This is a great opportunity for a dynamic candidate to work in different utilization review projects. Heavy emphasis on patient accounts and billing, ensuring that denials are completed in a timely fashion. We would also like a candidate who is tech-savvy and familiar with EPIC and Microsoft Office.The Utilization Review Coordinator reflects the mission, vision, and values of NM, adheres to the organization’s Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards.Responsibilities:The Utilization Review staff participates in the coordination of services across the continuum to facilitate the achievement of cost and quality patient care, appropriate utilization of resources and maximum financial reimbursement to the hospital and acts as a leader to achieve best practices of case management.They educate hospital personnel on clinical resource utilization management and act as liaison between the hospital and payers.To ensure the patients admitted to NM Palos meet the requirements for acute care and to assist in the transition of patients to the appropriate level of care.  Performs reviews on assigned case load to determine the appropriateness of stay relative to established admission criteria using Milliman and communicates that information to payers, physicians, and other members of the health care team.Executive Health Resources (EHR) assists in determining criteria regarding Medicare patients and Humana Medicare Replacements.  Provides accurate and timely documentation in Electronic Event Reporting System related to ongoing clinical status of the patient, plans for discharge and the utilization requirements as well as all certification/authorization numbers for patients.Run reviews through Milliman and, if criteria meets, discuss with Case Manager and if applicable sends commercial cases to Executive Health Resources (EHR).  Promotes quality care environment while maintaining fiscal responsibility for resource conservation by promoting multi-disciplinary practices which positively impact length of stay.In partnership with Case Management, maintains awareness of current reimbursement issues as they relate to area of case load.  Communicates all clinical information to managed care companies after admission to the hospital and throughout the patient's stay as necessary and updates anticipated discharge dates on a daily basis.  Assumes responsibility for professional development by maintaining knowledge of current trends and regulatory requirements in order to promote best practices.  Proactively utilizes excellent communication skills, verbal, written, and interpersonal to manage case loads effectively and to update other members of the healthcare team of relevant information particularly when cases are denied reimbursement or out of plan, to assure early intervention and continuity of care.  Assists in the implementation of the appeal process on cases where payment has been denied or retrospective review on pending certification.  Collaborates with members of the healthcare team, including the Attending Physician, regarding Milliman criteria for the most appropriate level of care to meet the healthcare needs of the patient, based on accepted standards, evidenced based practice and current research.  Identifies patient's that may require Case Management and communicates with Case Manager.  Ability to multi-task prioritizes cases, and use critical thinking when coordinating patients care and discharge plans.
