Oceans Healthcare
Utilization Review Coordinator
The Utilization Review Coordinator manages all utilization review and case management activities for the facility’s inpatient, partial hospitalization, and outpatient programs. They conduct concurrent reviews of all medical records to ensure criteria for admission and continued stay are met and documented, and ensure timely discharge planning. The Coordinator coordinates information between third‑party payers and medical/clinical staff, provides flow of communication, and supports a medical record that documents and supports the level and intensity of service rendered. All duties are performed in accordance with Joint Commission, Federal and State regulations, Oceans’ Mission, policies and procedures, and Performance Improvement Standards.
Essential Functions
Identify and report appropriate, under‑use, over‑use, and inefficient use of services and resources to ensure high‑quality patient care in a cost‑effective manner.
Review all inpatient, partial hospitalization, and outpatient records to determine appropriateness and clinical necessity of admissions, continued stay, rehabilitation, and discharge; assess timeliness of evaluations (H&Ps, psychiatric evaluation, CIA formulation, discharge summaries); identify under‑, over‑ or inefficient use of services.
Report findings to appropriate disciplines and/or committees; notify staff of deficiencies to enable corrective action; submit monthly reports to the PI Coordinator.
Coordinate communication flow between physicians/staff and third‑party payers regarding reimbursement requirements.
Attend mini‑treatment team and morning status meetings to obtain third‑party payer pre‑certification and ongoing certification requirements and share pertinent data.
Attend weekly treatment team meetings.
Conduct telephone reviews and follow through with documentation requests from third‑party payers.
Maintain abstracts with updates provided to third‑party payers.
Notify physicians/staff/patients of reimbursement issues.
Initiate and complete appeals for reimbursement denials; notify inpatients of denials.
Report all Hospital Issued Notices of Non‑coverage (HINN letter) to QIO monthly.
Conduct special retrospective studies/audits as determined by M&PS or other committees.
Ensure all authorization and denial information is in HCS at the end of each business day.
Perform other duties and projects as assigned.
Requirements Educational / Experience Requirements Associate’s Degree with an emphasis on healthcare or Bachelor’s degree in social services preferred. At least one year of psychiatric/chemical dependency experience with strong psychiatric/medical knowledge.
Qualifications / Skills Excellent assertive communication skills, writing and composition skills, and knowledge of CD‑psych treatment and discharge planning. Strong understanding of regulatory and fiscal reimbursement and utilization review. Demonstrated patient advocacy, ability to organize and prioritize high‑volume workload, data analysis, minimal supervision. Therapeutic intervention de‑escalation education required. Ability to maintain a positive work attitude and collaborate professionally with staff and third‑party payers. Competency in age, disability, and cultural diversity for patient needs. Must complete CPR certification and an Oceans‑approved behavioral health de‑escalation program.
Work Environment Subject to many interruptions and occasional pressure from multiple calls and inquiries. The position can be high‑paced and stressful; the candidate must cope mentally and physically to the atmosphere. The role requires spending approximately 90% of the time inside a building that offers protection from weather but not necessarily from temperature changes.
Seniority Level Entry level
Employment Type Contract
Job Function Health Care Provider
Industries Hospitals and Health Care
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Essential Functions
Identify and report appropriate, under‑use, over‑use, and inefficient use of services and resources to ensure high‑quality patient care in a cost‑effective manner.
Review all inpatient, partial hospitalization, and outpatient records to determine appropriateness and clinical necessity of admissions, continued stay, rehabilitation, and discharge; assess timeliness of evaluations (H&Ps, psychiatric evaluation, CIA formulation, discharge summaries); identify under‑, over‑ or inefficient use of services.
Report findings to appropriate disciplines and/or committees; notify staff of deficiencies to enable corrective action; submit monthly reports to the PI Coordinator.
Coordinate communication flow between physicians/staff and third‑party payers regarding reimbursement requirements.
Attend mini‑treatment team and morning status meetings to obtain third‑party payer pre‑certification and ongoing certification requirements and share pertinent data.
Attend weekly treatment team meetings.
Conduct telephone reviews and follow through with documentation requests from third‑party payers.
Maintain abstracts with updates provided to third‑party payers.
Notify physicians/staff/patients of reimbursement issues.
Initiate and complete appeals for reimbursement denials; notify inpatients of denials.
Report all Hospital Issued Notices of Non‑coverage (HINN letter) to QIO monthly.
Conduct special retrospective studies/audits as determined by M&PS or other committees.
Ensure all authorization and denial information is in HCS at the end of each business day.
Perform other duties and projects as assigned.
Requirements Educational / Experience Requirements Associate’s Degree with an emphasis on healthcare or Bachelor’s degree in social services preferred. At least one year of psychiatric/chemical dependency experience with strong psychiatric/medical knowledge.
Qualifications / Skills Excellent assertive communication skills, writing and composition skills, and knowledge of CD‑psych treatment and discharge planning. Strong understanding of regulatory and fiscal reimbursement and utilization review. Demonstrated patient advocacy, ability to organize and prioritize high‑volume workload, data analysis, minimal supervision. Therapeutic intervention de‑escalation education required. Ability to maintain a positive work attitude and collaborate professionally with staff and third‑party payers. Competency in age, disability, and cultural diversity for patient needs. Must complete CPR certification and an Oceans‑approved behavioral health de‑escalation program.
Work Environment Subject to many interruptions and occasional pressure from multiple calls and inquiries. The position can be high‑paced and stressful; the candidate must cope mentally and physically to the atmosphere. The role requires spending approximately 90% of the time inside a building that offers protection from weather but not necessarily from temperature changes.
Seniority Level Entry level
Employment Type Contract
Job Function Health Care Provider
Industries Hospitals and Health Care
#J-18808-Ljbffr