Utilization Review Coordinator, 40 Hour Days

Exemption Status:

Hiring Range:

Please note that the final offer may vary within this range based on a candidate's experience, skills, qualifications, and internal equity considerations.

Schedule Details:

Scheduled Hours:

Shift:

Hours:

Cost Center:

This position may have a signing bonus available a member of the Recruitment Team will confirm eligibility during the interview process.

At UMass Memorial Health, everyone is a caregiver - regardless of their title or responsibilities. Exceptional patient care, academic excellence and leading-edge research make UMass Memorial the premier health system of Central Massachusetts, and a place where we can help you build the career you deserve. We are more than 20,000 employees, working together as one health system in a relentless pursuit of healing for our patients, community and each other. And everyone, in their own unique way, plays an important part, every day.

I. Major Responsibilities:

1. Reviews data from admission screening to clarify admission diagnosis, establish appropriate length of stay and identify potential outliers.
2. Alerts the treatment team of patient coverage from third party payors. Elicits patient information from the treatment team that is detailed, descriptive, and indicative of current suicidal/ homocidality, or inability to care for self-based on their mental illness.

3. Communicates to third party payer on a regular basis the necessary information that justifies patient's hospital level of care.

4. Provides admission, continued stay and discharge clinical review, including clinical reviews, to payers in accordance with established standards, procedures, and policies.

5. Collaborates with physicians and the interdisciplinary team to plan, coordinate, implement, and evaluate patient care.
6. Serves as a resource to the treatment team in relation to timely discharge planning.
7. Acts as a liaison to third party providers to ensure appropriate communication in regard to the implementation of patient's treatment.
8. Reviews all charts daily for appropriate utilization of resources.
9. Clarifies third party coverage.

10. Communicate and facilitate the P2P process between physician advisor and payer physician advisor. Documents outcome.
11. Initialize and maintains utilization review worksheet.
12. Assess patients that current clinical presentation is congruent with hospital level of care. Contacts the treatment team as appropriate.

13. Collaborates with the third-party payers to anticipate denial of payment and proactively addresses issues contributing to a potential denial.

14. Collaborates with the Revenue Integrity and Denial teams to help to respond to insurance denials.

15. Documents Insurance denials, Avoidable days, and Administrative Necessary days in the patient EMR.

Standard Staffing Level Responsibilities:

1. Complies with established departmental policies, procedures, and objectives.
2. Attends variety of meetings, conferences, seminars as required or directed.
3. Demonstrates use of Quality Improvement in daily operations.
4. Complies with all health and safety regulations and requirements.
5. Respects diverse views and approaches demonstrates Standards of Respect and contributes to creating and maintaining an environment of professionalism, tolerance, civility and acceptance toward all employees, patients, and visitors.
6. Maintains, regular, reliable, and predictable attendance.
7. Performs other similar and related duties as required or directed.

All responsibilities are essential job functions.

II. Position Qualifications:

License/Certification/Education:

Required:
1. Master's degree in psychology, counseling, or Human Services or equivalent.

Experience/Skills:

Required:
1. Minimum of 3-5 years direct clinical experience.
2. Must have excellent negotiation skills as well as good written and verbal communication skills.
3. Prior working knowledge of psych medications helpful.
4. Assertive and creative in problem solving, systems planning and patient care management.

Preferred:
1. Prior case management experience.
2. Word/Excel experience.
3. Experience with DSM4R coding and Allen Cognitive Level (ACL).

Unless certification, licensure or registration is required, an equivalent combination of education and experience which provides proficiency in the areas of responsibility listed in this description may be substituted for the above requirements.

Department-specific competencies, including age-specific competencies, and their measurements will be developed and maintained in the individual departments. The competencies will be maintained and attached to the departmental job description.Responsible managers will review competencies with position incumbents.

III. Physical Demands and Environmental Conditions:

Position requires work indoors most often in an office environment. However, work may also include monitoring patients' movements and activities resulting in the need for rapid physical response to unsafe patient movements. This includes standing, walking, running, reaching, bending, lifting, and stooping.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.

We're striving to make respect a part of everything we do at UMass Memorial Health - for our patients, our community and each other. Our six Standards of Respect are: Acknowledge, Listen, Communicate, Be Responsive, Be a Team Player and Be Kind. If you share these Standards of Respect, we hope you will join our team and help us make respect our standard for everyone, every day.

As an equal opportunity and affirmative action employer, UMass Memorial Health recognizes the power of a diverse community and encourages applications from individuals with varied experiences, perspectives and backgrounds. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, national origin, age, disability, gender identity and expression, protected veteran status or other status protected by law.

If you are unable to submit an application because of incompatible assistive technology or a disability, please contact us at talentacquisition@umassmemorial.org. We will make every effort to respond to your request for disability assistance as soon as possible.