Utilization Review Coordinator

  • Exeter, NH
  • Exeter Hospital
  • Case Management
  • per diem limited
  • Req #: 7985
  •  Day Shift - Varied days as needed; per diem 8:00am-4:30pm
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Summary

Provides coordination of benefits and related services to specific patient groups to assure the highest quality of care is provided in a cost-effective manner. Works with insurers the PRO for Medicare and Medicaid billing physicians and a variety of other decision-makers for medical appropriateness.

Requirements:

  • Associate's degree or equivalent experience
  • 1-3 years experience RN license - NH or other Compact State
  • UR Certified within 1 year of hire

Major Responsibilities:

  1. Reviews all admissions and provides clinical information to third party payors as required by contracts.
  2. Maintains a working knowledge of nationally accepted criteria sets (Milliman and Interqual) for inpatient vs outpatient status.
  3. Attends complex discharge rounds on Wednesday when scheduled.
  4. Links Utilization Management with Case Management .
  5. Reviews notices of potential denials and respond appropriately; ie facilitate Physician to Physician appeals when appropriate and assist with construction of appeal letters.
  6. Tracks denial information for reporting to Quarterly UR Committee.
  7. Provides ongoing education to the medical; nursing and hospital staff on current utilization practices and documentation requirements.
  8. Collaborates with Pre-cert and Patient Accounts staff as needed to ensure proper payment.
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