The Utilization Review Coordinator is responsible for overseeing the Utilization Review Program. This includes the implementation of case management scenarios, consulting with all services to ensure the provision of an effective treatment plan for all patients, oversees the response to requests for services and interfaces with managed care organizations, external reviewers, and other payors.
STANDARDS OF PERFORMANCE
THE ESSENTIAL JOB FUNCTIONS ARE CATEGORIZED UNDER THE JCAHO STANDARDS OF PERFORMANCE.
1. Supervising and supporting performance improvement activities on a daily basis and assure that action is taken as needed and as authorized by organization policies and procedures.
2. Receiving and reviewing department/service performance measures and documentation to evaluate performance improvement activities and coordinate reports of findings to the Quality Council, Medical Executive Committee and Board.
3. Maintain records of the performance improvement performance measures and statistical tools used to describe studies performed or methodology.
4. Advise and assist all departments/services and committees accountable for performance improvement activities and coordinate reports of findings to the Quality Council, Medical
Executive Committee and Board.
5. Maintain a record of all completed reviews, evaluations and process improvement team activities.
6. Review incident reports, patient/physician surveys and patient complaints to determine the presence or absence of patterns and/or trends or opportunities for improvement in patient care outcomes, as well as the appropriateness of corrective action.
7. Attend and participate in appropriate committee and department or service meetings in which performance improvement activities occur.
8. Share data and information with appropriate committees and departments/services.
Program Planning and Treatment
1. Direct the response to request for services, including the initial response, the assessment and referral process, the designation of appropriate level of care, initiating of services, and follow up activity.
2. Review the effectiveness of the comprehensive interface with external reviewers, communicate with external reviewers and managed care organizations to assure timely and appropriate interactions,monitor outcomes of reviews and provide consultation as needed.
3. Review the quality of documentation provided at all levels of care to assure adequacy and clinical appropriateness.
4. Assure patients are receiving effective and appropriate treatment, based on the level of care.
5. Establish standards for customer relations and monitor the interactions between Case Management staff and customers to evaluate the effectiveness of customer service.
6. Direct the program services offered, consulting with facility management in the planning, development, implementation and evaluation of the case management program.
7. Maintain current awareness of mental health activities in the community.
8. Maintain an awareness of community and market-related activities which includes knowledge of the activities of other providers, needs of local payers and the political climate related to mental health.
9. Participate in clinical team analysis and evaluation of current services offered at the facility.
10. Strategically solve problems that encompass the larger view of the organization, and establish goals by utilizing an understanding of organizational dynamics in planning and problem solving.
11. Remain current on all clinical techniques, and provide direction to staff and facility personnel.
12. Participate in developing, justifying and controlling the annual budget for department personnel, facilities and equipment.
13. Ensure strategic program goals and objectives are consistent with overall facility goals and objectives. 14. Develop goals and objectives, policies and procedures related to the operational needs of the programs scenarios.
15. Consult with facility management in the development and facilitation of program activities which assure an optimal therapeutic experience for all patients
16. Participate with ensuring that individual patients and their families are involved in the development of individualized treatment plans.
18. Maintain an active involvement and awareness of all patient admissions, discharges and transfers.
19. Meet regularly with program managers and the Medical Director and program staff to ensure compliance with program goals and objectives.
20. Serve on Facility Committees and attend meetings as assigned.
21. Provide services to current referral sources to assure their satisfaction and continued associations.
22. Develop and maintain a system to minimize and address denials in consult with the facility Business Office Manager and CFO.
Personnel Management and Staffing
1. Maintain and allocate a well-qualified core of staff resources.
2. Assure that hiring, disciplinary actions and termination procedures are conducted in accordance with hospital policies.
3. Involve appropriate facility management in all decisions, and review these decisions with COO prior to implementation.
4. Assure adequate supervision and evaluation processes for all staff members and delegate these responsibilities as appropriate.
5. Assure adequate orientation for new employees of the Case Management Department.
6. Provide for educational needs and professional development of staff.
7. Ensure that the staff schedule and configuration will meet the needs and demands of the patient population and census and adjust it accordingly.
8. Ensure an adequate system of communication and reporting is maintained between all staff members, as well as other departments involved in the ongoing operation of the program.
9. Create a structure that best meets the needs of the organization, particularly department organization related to supervision and assignment of staff.
10. Routinely review job assignments and utilization of staff.
1. Conduct department meetings on a regular basis.
2. Work with clinical leadership to ensure interdisciplinary treatment planning is organized with participation of all appropriate clinical disciplines.
3. Ensure all patient, family and referral complaints are promptly handled.
4. Coordinate the collection of outcome data within the company deadline.
Continuous Quality Improvement
1. Ensure that a system is developed to provide continuity of care and communication with family and appropriate referral sources, and ensure the system is evaluated and reviewed regularly.
2. Daily reporting of denials to CFO.
3. Ensure the department meets Joint Commission, CMS and federal and state regulatory requirements.
4. Develop and implement a Performance Improvement tracking system, evaluate the results monthly, and report results to the Performance Improvement Committee in a timely manner.
5. Ensure that all deficiencies identified through the performance improvement analysis are addressed with appropriate problem solving actions.
6. Review all department risk management occurrence and ensure that complete and timely reports are submitted to Risk Management.
7. Analyze statistical data of the program to determine and respond to trends.
1. Implement planning and teaching staff documentation training.
2. Serves on Facility Committees as assigned.
3. Accepts responsibility for professional growth and development.
4. Demonstrates a professional attitude and supports the objectives of the Facility philosophy through internal and external communications and interactions with all levels of staff, patients, family members, guests, community and referral sources.
5. Adhere to facility, department, corporate, personnel and standard policies and procedures.
6. Attend all mandatory facility in-services and staff development activities as scheduled.
7. Adhere to facility standards concerning conduct, dress, attendance and punctuality.
8. Support facility-wide quality/performance improvement goals and objectives.
9. Maintain confidentiality of facility employees and patient information
Note: The essential job functions of this position are not limited to the duties listed above.
KNOWLEDGE, SKILLS, AND ABILITIES
1. Knowledge of external review organization (i.e. managed care, Medicare, Medicaid.
2. Knowledge of patients’ rights, advanced directives, adult and child abuse laws, and emergency detention.
3. Working knowledge of payor resources and financial planning.
4. Demonstrate willingness to acquire knowledge and expertise in complex patient care planning.
5. Skill in organizing and prioritizing workloads to meet deadlines.
6. Skill in telephone etiquette and paging procedures.
7. Effective oral and written communication skills.
8. Excellent leadership and negotiation skills.
9. Excellent customer relations skills.
10. Ability to manage conflicting situations.
11. Ability to be relationship focused by interacting with multiple individuals with diversified roles and perspectives.
12. Ability to operate in an unstructured environment, orchestrate a myriad of activities and to manage multiple priorities within complex systems.
13. Ability to tolerate ambiguity, uncertainty and change.
14. Ability to work at a rapid pace.
15. Ability to manage and plan one’s own schedule with calls, assessment fluctuations and demands as required.
16. Ability to communicate effectively with patients and co-workers.
17. Ability to adhere to safety policies and procedures.
18. Ability to use good judgement and to maintain confidentiality of information.
19. Ability to work as a team player.
20. Ability to demonstrate tact, resourcefulness, patience and dedication.
21. Ability to accept direction and adhere to policies and procedures.
22. Ability to recognize the importance of adapting to the various patient age groups (adolescent,adult and geriatric).
23. Ability to work in a fast-paced environment.
24. Ability to meet corporate deadlines.
25. Ability to react calmly and effectively in emergency situations.
PHYSICAL, MENTAL, AND SPECIAL DEMANDS
1. Ability stand, or walk up to six hours.
2. Ability to stand up to two hours.
3. Ability to spend 20% of the work day outdoors in temperatures varying from -30° F. to 100°F. and 80% of the wok day indoors in temperatures varying from 60°F. to 85°F.
4. Ability to occasionally push/pull wheeled carts from 200 pounds (i.e. crash carts, patients on stretchers or in wheelchairs).
5. Ability to frequently lift and carry up to 10 pounds (charts, records); occasionally lift and carry up to 100 pounds.
6. Ability to see well enough to read written material and discern a variety of odors.
7. Ability to handle hazardous/infectious waste on an occasional basis.
8. Ability to work in an environment where the noise level is frequently high; where chemicals are frequently used for cleaning; where mechanical and electrical hazards may be present; and where dust, mist and steam are frequently generated in housekeeping tasks.
MACHINES, TOOLS, EQUIPMENT, AND OTHER WORK AIDES:
1. Computer and software programs.
2. Telephone and paging systems.
4. Copy machine.
5. Medical records.
6. Policies, procedures, plans and program manuals.