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Employment Type:

Part time

Shift:

Description:

The Utilization Review (UR) Coordinator works, in collaboration with a multidisciplinary team that includes, but is not limited to, physicians, nurses, patient access, and billing staff, along with external insurance payers, to ensure patients progress along the continuum of care in an efficient and cost-effective manner that ensures quality outcomes. UR Coordinator utilizes established guidelines to support appropriate level of care throughout hospitalization and serves as a liaison between the hospital and external payers on issues related to severity of illness and intensity of service for patients to ensure appropriate and timely utilization of hospital services.

Essential Functions and Responsibilities

Uses approved criteria for admission and continued stay reviews to ensure appropriate setting and timely implementation of plan of care. Effectively organizes and sets priorities on assignment caseload. Monitors patient's progress across the continuum and intervenes as necessary to ensure quality services that are efficient and cost effective. Collaborates with admitting and/or attending physicians regarding appropriate level of care/status determination. Consults with Physician Advisor and administrative leadership as necessary for those patients not meeting medical necessity for acute care. Knowledgeable of Medicare, Medicaid, and non-governmental payer regulations for patient care requirements. Proficiency in MCG and INTERQUAL Criteria applications. Timely submission and completion of all initial, concurrent and discharge reviews. Responds to requested insurance reviews based on contractual obligations. Actively manages concurrent denials. Demonstrates service excellence by providing complete clinical information to government and non-governmental review organizations following HIPAA guidelines. Identifies, processes, and documents CC44 accounts appropriately. Partners with case management onsite staff for delivery of any regulatory documentation. Documents all pertinent communication regarding certification in the hospital EMR. Serves as a resource to the healthcare team regarding utilization standards. Evaluate hospitalized patients to ensure they are receiving services in the most appropriate and cost-effective level of care in collaboration with attending physicians, Physician Advisors, and external payors. Participates in denials management and auditing duties as assigned. Participates in the Utilization Review Committee as assigned. Maintains good rapport and cooperative relationships both internally and externally. Approaches conflict in a constructive manner. Helps to identify problems, offer solutions, and participates in their resolution. Demonstrates self-directed learning. Maintains a working knowledge of applicable Federal, State and local laws and regulations, Trinity Health's Organizational Integrity Program, Standards of Conduct, as well as other policies and procedures to ensure adherence in a manner that reflects honest, ethical and professional behavior. Maintains the confidentiality of information acquired pertaining to patients, physicians, employees, and visitors to Trinity Health facilities. Discusses patient and hospital information only among appropriate personnel in appropriately private places. Assumes responsibility for performance of job duties in the safest possible manner, to assure personal safety and that of coworkers, and to report all preventable hazards and unsafe practices immediately to management. Behaves in accordance with the Mission, Vision, and Values of St. Mary’s Health System. Attends team huddles and meetings when working; if unable to attend then review of notes/minutes from meetings is required. Staff are accountable for knowing content of discussions.

Professional Development

All Registered Nurses are expected to engage in professional role activities, including leadership, appropriate to their education and position. Registered nurses are accountable for their professional actions to themselves, their healthcare consumers, their peers and to society. The UR Specialist is recognized as an expert in technical skills and professional practice. The UR RN is expected to contribute to the professional growth of others by acting as a preceptor, clinical coach, and mentor.

OTHER FUNCTIONS AND RESPONSIBILITIES

_Performs other duties as assigned._

Required Education, Experience and Certification/Licensure

**Licensure/Certification/Registration:** Current GA RN license. BLS required.

**Education:** Must be a graduate of an accredited school of nursing, BSN recommended.

**Experience:** Three to five years related experience and clinically relevant knowledge.

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.

Our Commitment to Diversity and Inclusion

Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.

EOE including disability/veteran