POSITION TITLE:
Utilization Coordinator
REPORTS TO:
Director of Medical Management
DATE:
May 21, 2014
JOB SUMMARY:
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Responsible for review of all inpatient and outpatient admissions to the hospital for
appropriateness, facilitating the accurate representation of severity of illness by improving
the quality of the physician’s documentation through clinical documentation improvement
and manages all access points for admission to the hospital including but not limited to
Emergency Department admissions, direct admissions, transfers into and out of the facility
and admissions from outpatient areas.
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Evaluates the medical necessity, appropriateness and efficient use of health care services of
all hospitalizations inpatient or outpatient.
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Skilled with the application of InterQual criteria, works collaboratively with the physicians,
healthcare team and the care coordinator to optimally certify the level of care and facilitates
the patient’s movement through the continuum of care as appropriate.
KNOWLEDGE, SKILLS & EXPERIENCE REQUIRED:
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RN or Bachelor’s Degree in Nursing required; Bachelors in related field considered
3-5 years recent hospital based patient care
3-5 years Milliman or InterQual experience preferred
HMO, managed care, PPO, Utilization Management/medical management experience a
plus
Current professional licensure in nursing or professional field of certification in the state of
Missouri
Strong computer skills, excellent communication skills, team building and leadership ability
WORKING CONDITIONS:
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Work environment is located in a comfortable indoor area
Conditions such as noise, odors, cramped workspace and/or fumes could sometimes
cause discomfort
Frequent periods of concentrated or forced attention will be needed to interpret visual,
auditory, and sensual inputs
Alternate/extended shifts may be required
Alertness and careful attention to detail will be required
RELATIONSHIPS: Reports directly to the Director of Medical Management
PHYSICAL REQUIREMENTS:
Frequency Scale: 1 = Rarely/Never; 2 = Occasionally; 3 = Frequently and 4 = Consistently
Activity
1
Climbing
X
2
3
4
Activity
3 4
- Loud
Commands or
Public
Speaking
Pulling
X
Hearing
Pushing
X
- Normal
Conversations
X
Reaching
X
- Other
Sounds or
Auditory
Alarms
Standing
X
Vision
Sitting
X
X
X
Activity
1
2
3 4
Lifting
- Normal
Conversations
X
Walking
2
Talking
Hand-Eye
Coordination
Kneeling
Stooping
1
X
X
- Over 50#
X
- Over 25#
X
- Under 25#
X
X Memory
X
- Acuity, Near
- Acuity, Far
X
- Color Vision
X
- Short Term
X
- Long Term
X
X Analytical
Thinking
Attention to
Detail
Concentration
X
X
X
Range of
Motion
Use of
Hands
- Arms
X
- General
Manual
Dexterity
- Shoulders
X - Keyboard
Decision
Making
X
X Reading
X
X Writing
X
Skills or
Typing
AGE CATEGORIES OF INDIVIDUALS SERVED:
Demonstrates the knowledge and skills necessary to provide age-appropriate care to the
following patient population:
____ Neonatal (1-30 days)
____ Adolescent (13-18 yrs)
__X_ No Patient Contact
____ Infants (30 days-1 yr)
____ Adult (19-70 yrs)
____ Children (1-12 yrs)
____ Geriatric (70+ yrs)
CORE DEPARTMENTAL COMPETENCIES:
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Monitors use of healthcare resources, collaborates with physicians to assure patient receives
diagnostics/evaluations in the proper setting (i.e. inpatient vs. outpatient).
Maintains current knowledge of Condition Code 44, Hospital CoP’s and CMS (Medicare)
rules and regulations.
Serves as an expert resource to physicians, healthcare staff in the application of InterQual
and use of evidence based practices.
Serves as patient advocate and enhances a collaborative relationship between the physician
and multidisciplinary team with the patient and family to maximize informed decisions.
Communicates effectively with third party payors regarding certification, completes initial
review prior to or at time of admission.
Maintains knowledge of InterQual medical necessity criteria and applies appropriately.
Identifies the need to clarify documentation through quality audits in records and initiates
communication with physicians utilizing appropriate ‘query’ tools in order to capture
documentation in the medical record to accurately support the patient’s severity of illness.
Demonstrates knowledge of documentation requirements and guidelines.
Assists in the improvement of overall quality and completeness of clinical documentation by
ensuring that documentation clarification with physicians has been recorded in the patient’s
chart.
Reviews clinical data for ED admits, makes level of care recommendations to the ED
physician and obtains any additional clinical information to assist in the level of care
determination.
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Manages all direct admits, clarifies level of care orders and performs InterQual screening as
appropriate. Acquires additional information if necessary to assist in the level of care
determination.
Reviews all requests for changes in status for admission from the PACU or any outpatient
areas. Applies InterQual criteria to determine appropriateness for the level of care requested
and consults with attending if necessary.
Insures the operative procedure performed is the operative procedure prior-authorized with
the third party payor and communicates any variance.
Serves as a resource for facilitating patient transfers, including but not limited to, obtaining
or providing clinical information from/to the referring/accepting facility. Performs clinical
reviews of all inbound transfers for appropriateness.
Demonstrates a working knowledge of HIPAA guidelines and utilizes them in all aspects of
communications with customers.
Cooperates/communicates with the QIO when a Medicare patient has appealed their
discharge.
Consults the Physician Advisement process to resolve issues and refers appropriate cases per
established protocol.
Adheres to and implements the Utilization Management Plan per CMS Conditions of
Participation.
Reports and documents adverse events and reportable conditions.
Consistently follows departmental procedures regarding level of care (service) changes.
Discusses cases with particular issues relating to utilization appropriateness with
Manager/Director and notifies appropriate peoples when indicated.
Displays a high level of flexibility, adaptability and organizational skills in response to the
workload and effectively prioritizes work while maintaining productivity.
Demonstrates and conveys a favorable image of the Medical Center.
Presents a professional appearance in accordance with dress code standards.
Demonstrates attendance patterns to reflect commitment to the job requirements and patient
care needs.
Assists with collection of data for case management metrics per the UM Plan.
Supports the Medical Center quality improvement process by identifying and appropriately
communicating potential quality issues and participating in focused quality monitoring (i.e.
concurrent notification of ADRS, sentinel events, etc.).
Contributes to the development of competencies related to job functions and participates in
competency evaluations.
Participates in department based Performance Improvement activities.
Reviews patient’s medical record for over, under and inappropriate utilization. Reviews for
justification of patient admission and continued stay. Conducts timely and accurate
interventions and follow-through.
Informs Patient Financial Services of patients in need of financial counseling.
Tracks and documents avoidable days and readmissions with proactive, concurrent action
taken when indicated.
_____________________________
Director of Medical Management
_______________
Date
____________________________
Employee
_______________
Date