Utilization Review Coordinator

Description

Under direction, to review, monitor and assess utilization of hospital services; to administer Utilization Review procedures as required under federal, state, and county regulations as well as Valley Medical Center's Utilization Review plan or Public Health CCS guidelines.
The established list may be used for full-time/part-time/extra help/pm shifts/weekends vacancies as they occur.
Learn more about Santa Clara Health System at:
scvmc.org, oconnor.org, stlouise.org
Twitter I @scvmctalent
Facebook I facebook.com/SCVMC
LinkedIn | linkedin.com/SCVMC

Typical Tasks

• Monitors admissions of patients for hospital care;
  
• Reviews justification for services;
  
• Reviews and certifies patient stays, need for acute hospitalization and/or indicated outpatient services, and need for length of stay extensions;
  
• Prepares documentation related to appropriate payment for services;
  
• Maintains close liaison with all levels of professional hospital staff;
  
• Maintains liaison with other county departments and outside health care agencies;
  
• Investigates and documents rejected insurance claims;
  
• Participates in and provides assistance with patient audit activities;
  
• Facilitates compliance with Utilization Review regulations;
  
• Conducts concurrent review of all inpatients;
  
• Traces medical billings to be paid;
  
• Acts as resource in referral of outpatient discharges;
  
• Prepares and maintains appropriate records and/or documents and submits reports as required;
  
• Maintains a working knowledge of current regulations affecting patient care services and related fiscal programs;
  
• May assist in preparation of billing claims;
  
• May perform the above duties and provide medical case management primarily in relation to patients under the California Children's Services program;
  
• Performs other related duties as assigned.

Employment Standards

Possession of a current California RN license.
Experience Note: The knowledge and abilities required would normally be acquired by two (2) years of recent nursing experience in an acute care hospital setting. Utilization Review experience in an acute care setting is desirable.
Knowledge of:

• Hospital organization, operations and procedures;
  
• Federal and state health care laws and regulations common to the operation of hospitals in California;
  
• Regulations of intermediary agencies pertaining to hospital stay coverage (e.g. Medicare and Medi-Cal);
  
• Medical terminology and related levels of care and treatment;
  
• Data processing systems as relating to Utilization Review;
  
• Evaluation and assessment techniques;
  
• Record keeping and reporting procedures.

• Maintain effective reporting systems;
  
• Collect and record data;
  
• Interact with all levels of hospital staff;
  
• Maintain close liaison with hospital resources;
  
• Interpret health care laws, regulations and procedures;
  
• Evaluate data and statistics;
  
• Work independently;
  
• Communicate effectively orally and in writing.