Admissions / Utilization Review Coordinator

POSITION SUMMARY

Pay range: $25.62/hr - $36.12/hr

 

The Admissions/Utilization Review Coordinator is the primary facilitator of new referrals, admissions, and registration to the Geriatric Psychiatry Unit, works independently to process and coordinate referrals while working closely with the providers, nurse leader(s), and unit manager. Verifies insurance coverage, obtains initial insurance authorizations, and conducts concurrent utilization reviews for patients during their admission, processes insurance denials and appeals.

 

KEY RESPONSIBILITIES

Performed majority of the time:

·         Creates a referral packet for a patient admission to Geriatric Psychiatry Unit and submits to the provider for assessment.

·         Keeps a log of all referrals including admissions and declinations.

·         Communicate with Nurse Leader, Manager or Provider daily to determine bed status.

·         Completes registration of patient into the EHR system and makes assignment of unique medical record number and obtains Care Everywhere access if available.

·         Documents insurance communications in the EHR and sends discharge summaries to insurance companies.

·         Tracks patient charts with Medicare as primary payor and reports on length of stay.

·         Obtains verification and documents insurance benefits at the time of admission.

·         Ensures the patient’s legal status is clarified prior to admission and obtains appropriate supporting documentation.

·         Performs Utilization Review for each patient using established medical necessity guidelines.

·         Communicates with payers regarding authorization and medical necessity.

·         Discusses cases with providers, attends Interdisciplinary Treatment Team Meeting and discusses barriers to discharge.

·         Educates providers regarding documentation requirements that support medical necessity determinations.

·         Facilitates insurance Peer to Peer discussions.

·         Assesses whether there is a basis for written appeal for cases in which payment is denied due to medical necessity concerns.  Seek input from Providers as needed.

·         Composes persuasive and grammatically correct written appeals for claims denied by payers for lack of medical necessity whether denied pre or post payment. 

·         Coordinates and processes Medicare Discharge appeals with the QIO.

·         Conducts secondary reviews for peers, assessing appropriate classification and medical necessity.

·         Communicates closely with the Interdisciplinary Treatment Team about patients’ expected hospital course, expected discharge date, goal LOS, and authorization status.

·         Other UM activities as assigned.

Performed occasionally but critical to successful performance of the job:

·         Sends appropriate information to Patient Accounting.

·         Assists with audits as requested.

Decision making and budget responsibilities:

·         Decision impact limited to the employee and the operations of the unit.

·         No budget responsibility but supports budget planning and the unit manager with the data collection.

JOB SPECIFICATIONS

 

Education:

Required

·         N/A

Preferred

·         N/A

Experience:

Required

·         N/A

Preferred

·         Experience of at least two (2) years working in a healthcare office setting such as an insurance company, revenue cycle/billing/coding, admit or intake coordinator.

·         Experience in handling preauthorization requests, appeals, registration, scheduling appointments, and patient data entry.

Licenses, Certifications and/or Registrations:

Required

·         N/A

Preferred

·         N/A

Job Related Skills, Abilities and Behaviors:

Required

·         Demonstrates critical thinking skills in problem solving and decision-making.

·         Demonstrates ability to work in a team situation and works collaboratively and maintains active communication with the interdisciplinary care team.

·         Demonstrates an understanding of insurance payor language and ability to provide clinical information for review in a timely manner.

·         Displays a positive attitude, team concept, and ability to multi-task.

·         Excellent telephone communication skills: must speak professionally, clearly, and pleasantly while projecting care and helpfulness.

·         Work at an efficient and productive pace, handle interruptions appropriately and meet deadlines.

·         Must be detail-o