Position Overview:

The Outpatient Utilization Review (UR) Coordinator functions out of the RCA office. The Outpatient UR Coordinator manages utilization of patient care in all RCA outpatient programs and ensures all personnel providing patient care comply with practice and documentation related to outpatient processes and regulations of the State as well as accrediting bodies. This includes ensuring all patients are authorized for treatment via their insurance or self-pay funding source and that the treatment team is aware of authorized time for treatment. Additionally, the UR Coordinator is responsible for reviewing medical records and communicating missing components required by RCA standards as well as Joint Commission and insurance payor standards to the Clinical Supervisor and Clinical Director of the respective outpatient programs. The Outpatient UR Coordinator analyzes insurance, governmental, and accrediting agency standards to determine criteria concerning admissions, treatment, and extending length of stay for patients in RCA outpatient programs. The Outpatient UR Coordinator must act as an advocate for extending patient treatment at all times to support the clinical treatment plan. They must provide education to the clinical team surrounding medical necessity criteria and assist the treatment team to identify all medical necessity criteria in order to facilitate insurance coverage. They must be familiar with standard concepts, practices, and procedure for all ASAM outpatient levels of care. Ensures any insurance denials are communicated to treatment team immediately and manages any appeals in order to expedite coverage for appropriate level of care.

Specific Responsibilities:

Works on UR team and assists other members of the treatment team to ensure appropriate utilization of services Provides information at the request of other members of the UR team and communicates all utilization issues that may compromise patient’s treatment immediately to treatment team Consistently works to assist with the development of new and innovative systems/treatment planning ideas to help maximize patient days. Assists other members of the UR team with concurrent review and precertification of services when needed. Attends outpatient site treatment team. Completes discharge notification calls to the insurance company within one business day of patient discharge. Responsible for ensuring all data is documented to extend length of stay Works closely with insurance carriers to provide accurate information and obtain authorization of coverage. Documents all efforts to obtain authorization, authorized days, and details related to insurance denial and appeal efforts clearly and thoroughly in EMR. Ensures all outpatient processes are completed accurately in order to ensure proper billing (such as progress notes completed and all EMR processes are followed) Provides reliable trending analysis of current and past data related to length of stay and days authorized by specific insurance companies. Shares knowledge and experience working with in-network and out-of-network benefits to help maximize patient days. Work closely with all members of the outpatient treatment teams. Exhibits knowledge of all continuums of care, including admission assessment and continued stay criteria. Ensures quality and quantity of documentation in medical records This job description is not designed to cover or contain comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

Education and Experience:

Bachelor’s degree and 3+ years’ related experience Excellent verbal and written communication skills. Excellent organizational skills with the ability to prioritize workload Proficiency in Microsoft Office Suite, including Word, Excel and PowerPoint

Competencies:

Customer Service: Demonstrates concern for meeting internal external customers’ needs in a manner that provides satisfaction for the customer within the resources that can be made available.

Problem Solving:Identifies problems, involves others in seeking solutions, conducts appropriate analysis, searches for best solutions; responds quickly on new challenges.

Communication: Comfortable using a broad range of communication to different audiences in diverse solutions.

Project Management: Coordinates the diverse components of the projects by balancing scope, time, cost, and quality.

Work Environment: May work in a variety of environments including professional offices, clinics, hospitals, or out-patient facilities. They spend much of their time on their feet, actively working with patients.

Physical Demands: While performing the duties of this position, the employee is regularly required to talk or hear. The employee frequently is required to use hands to finger, handle or feel objects, tools or controls. The employee is occasionally required to stand; walk; sit; reach with hands and arms; climb or balance; and stoop, kneel, crouch or crawl. The employee must occasionally lift and/or move objects up to 25 pounds. Specific vision abilities required by this position include close vision, distance vision, color vision, peripheral vision and the ability to adjust focus.

Travel: Travel is primarily local during the business day, although some out-of-the-area and overnight travel may be expected