Primary Function:
Under CNO supervision, the Utilization Coordinator provides utilization review, Amkai chart surveillance and denials management for the inpatient case load. This role utilizes the nationally recognized Milliman Care Guidelines/Criteria to assess the patient's need for inpatient care as well as determining the appropriate level of care. The Utilization Coordinator interfaces with the medical team, physician office staff, other staff members as well as payers.
Essential Duties and Responsibilities:
Obtains the information necessary to assess a patient's clinical condition, identify ongoing clinical care needs and ensure that the patients receive services in the setting that best meets their needs.
Determines the patient's insurance coverage and eligibility to facilitate completion of the utilization review process using payer specific criteria.
Uses MCG guidelines to establish medical necessity and determine inpatient versus observation status of the patient.
Utilizes clinical skills to provide and facilitate utilization review, continued stay reviews and utilization management of inpatient cases.
Reviews assigned ICD- 10 codes and CPT codes for appropriate reimbursement.
Reviews prior authorization / Observation stay requests to determine appropriate care and setting.
Reviews all inpatient Amkai chart records to ensure accuracy and completeness; monitors and reports trends of inappropriate utilization of resources or quality issues to the Medical Director(s).
Collaborates with various staff within the provider's network as well as functioning as a resource to the clinical team regarding authorization policies, approval criteria, practice guidelines, and alternate treatment options if admission is not an indication for a patient.
Remains current on clinical practice and protocols that affect clinical reimbursement.
Participates in meetings and committees related to this role and represents the department as necessary.
Collaborates with billing office staff to review denied claims and assists with the appeals process.
Performs other related duties as assigned.