Overview: In accordance with the objective and goals of the Utilization Management Plan, the UM Coordinator coordinates and monitors daily activities of the utilization management functions of the Care Management Department, ensuring 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.
Responsibilities: Review Activities for the Emergency Department: Status reviews, admission reviews, admission denial, continued stay review, continued stay denial, termination of benefits, communication of information to insurance company, billing certification, concurrent managed care, denial appeals, retrospective medical record utilization review. Obtains and evaluates medical records for inpatient admissions to determine if required documentation is present. Obtains appropriate records as required by payer agencies and initiates physician advisors as necessary for unwarranted admissions. Conducts ongoing review and discusses care changes with attending physicians and others. Performs chart reviews for appropriateness of admission and continued hospital stay applying appropriate clinical criteria. Performs admission review within 24 hours or the first business day. Refers cases not meeting criteria to the physician advisor for determination and action. Must be able to work weekends.
Qualifications: RN required Certified Case Manager preferred Licensed as a registered nurse in the state of New Jersey Previous case management/utilization review experience required Minimum of five years experience in the acute care setting Previous case management/utilization review experience required Knowledge of DRG payer issues and documentation requirements Knowledge of federal and state regulations, third party payers/managed care principles Knowledge of InterQual/Millman criteria and other guidelines for medical necessity, appropriate level of care and concurrent patient management Knowledge of health care delivery system, utilization review and case review procedures Computer skills to include Microsoft Word, Excel and basic data entry Strong organizational and problem solving skills Excellent oral, written and interpersonal skills