Utilization Review Coordinator Resume Samples

Description :

1. Analyzes and reviews inpatient and outpatient treatment plans to ensure compliance with medical necessity criteria.
2. Collaborates with physicians and clinical teams to maintain optimal care quality and resource utilization.
3. Implements proactive management strategies for acutely and chronically ill patients, improving quality outcomes.
4. Provides feedback to healthcare providers on discharge plans and covered services, ensuring patient needs are met.
5. Facilitates regular review rounds to discuss patient status and address barriers to discharge.
6. Identifies training needs and addresses documentation issues with management for continuous improvement.
7. Coordinates interdisciplinary efforts to support continuity of care and authorizations for covered services.

Experience

7-10 Years

Level

Management

Education

MSN

Description :

1. Utilizes established criteria to assess medical necessity for continued patient care and discharge readiness.
2. Conducts concurrent reviews via telephonic and on-site evaluations of treatment plans.
3. Monitors and reports trends in resource utilization and quality of care to the Medical Director.
4. Collaborates on discharge planning initiatives aimed at minimizing readmissions.
5. Evaluates patient admissions against criteria to determine appropriate length of stay and care requirements.
6. Facilitates communication among clinical teams to ensure cohesive treatment approaches.
7. Maintains accurate and comprehensive documentation in electronic health records.

Experience

5-7 Years

Level

Executive

Education

MCP

Description :

1. Coordinated precertification and prior authorization processes for diverse patient cases.
2. Managed incoming communications, ensuring efficient triage and case management.
3. Identified and entered referral requests into the Utilization Management system per guidelines.
4. Responded to inquiries from clients and providers, enhancing service delivery.
5. Conducted clinical screenings and authorized initial treatment sessions based on benefit checks.
6. Built strong relationships with clients, ensuring timely and appropriate responses to requests.
7. Trained new associates on operational procedures and best practices for case management.

Experience

2-5 Years

Level

Junior

Education

MA

Description :

1. Analyzed patient records to determine the legitimacy of admissions, treatments, and lengths of stay, ensuring compliance with healthcare standards.
2. Reviewed patient applications for admission and coordinated with the utilization review committee to meet established criteria.
3. Collaborated with medical and nursing staff to assess treatment plans and determine appropriate lengths of stay.
4. Abstracted and maintained accurate statistics from patient records, ensuring timely reviews according to established diagnostic criteria.
5. Anticipated and planned for patient needs throughout the care continuum, from pre-admission to post-discharge.
6. Coordinated interdisciplinary efforts to facilitate timely patient discharges and effective care transitions.
7. Developed and implemented strategies to enhance patient care quality and regulatory compliance.

Experience

5-7 Years

Level

Executive

Education

BSN

Description :

1. Ensured comprehensive documentation of authorizations, coverage periods, and denials within the system.
2. Actively participated in treatment planning sessions, representing patient benefit parameters.
3. Conduct comprehensive reviews of patient care for medical necessity and appropriateness.
4. Coordinated retrospective reviews and managed appeal processes for service denials from external payors.
5. Monitored treatment and follow-up care provided to clients, ensuring support in all areas.
6. Negotiated reimbursement on a case-by-case basis in line with guidelines from administrators.
7. Maintained up-to-date knowledge of Joint Commission standards and documentation requirements.

Experience

5-7 Years

Level

Management

Education

BSN

Description :

1. Clarifies treatment plan requests by liaising with providers to ensure accurate clinical information.
2. Collaborates with claim examiners to resolve issues and provide necessary clinical documentation.
3. Assists in planning and conducting federally mandated quality assurance reviews for compliance.
4. Analyzes treatment plans to ensure alignment with insurance criteria and best practices.
5. Monitors patient outcomes to identify areas for improvement in care delivery.
6. Educates healthcare teams on compliance standards and utilization review processes.
7. Facilitates interdisciplinary meetings to enhance communication and streamline patient care.

Experience

5-7 Years

Level

Executive

Education

BSN

Description :

1. Prepare detailed reports on utilization patterns and recommendations for management.
2. Ensured adherence to federal and managed care reimbursement policies.
3. Acted as a liaison between members, providers, and benefit representatives to address concerns and resolve issues.
4. Managed claim disputes, denials, and balance billing in accordance with contractual agreements.
5. Coordinated agreements for out-of-network care, optimizing resource utilization.
6. Maintained data integrity by entering demographics and utilization review details accurately.
7. Conducted training sessions for staff on compliance and best practices in utilization review.

Experience

7-10 Years

Level

Management

Education

BSN

Description :

1. Collaborates with physicians and care teams to assess and evaluate utilization review activities.
2. Ensures compliance with Medicare regulations regarding inpatient utilization and patient privacy.
3. Facilitates communication between care management and third-party payers to optimize patient care.
4. Conducts thorough reviews of cases for medical necessity and appropriateness of care.
5. Utilizes data-driven insights to inform treatment plan evaluations.
6. Develops and implements policies to enhance operational efficiency.
7. Trains new staff on utilization review protocols and compliance standards.

Experience

5-7 Years

Level

Junior

Education

BSN

Description :

1. Conducted comprehensive reviews of patient admissions and inpatient stay appropriateness to ensure quality care.
2. Performed concurrent chart reviews, including assessments of treatment plans and discharge readiness.
3. Collaborated with medical staff to devise discharge plans aligned with hospital-specific length of stay norms.
4. Liaised with insurance companies to communicate patient progress and secure necessary authorizations.
5. Analyzed data to identify trends in resource utilization and patient outcomes.
6. Develop and implement strategies to improve utilization review efficiency and effectiveness.
7. Developed and maintained documentation to support quality improvement initiatives and regulatory compliance.

Experience

10+ Years

Level

Executive

Education

BSN

Description :

1. Gathered comprehensive information needed for utilization review processing from both internal and external sources, adhering to established policies.
2. Managed distribution of incoming correspondence, faxes, and mail, ensuring timely uploads of review documents into a paperless system.
3. Developed and maintained efficient workflows for utilization review processes, improving response times.
4. Conducted regular audits of utilization review documentation to ensure accuracy and compliance.
5. Collaborated with healthcare providers to clarify treatment plans and improve care coordination.
6. Communicate effectively with patients and families regarding care options and resources.
7. Utilized data analytics to track and report on utilization metrics, informing quality improvement initiatives.

Experience

10+ Years

Level

Senior

Education

BSN

Description :

1. Specialized in conducting utilization reviews for private insurers and Medicaid, ensuring adherence to coverage criteria.
2. Performed daily assessments of case records based on Milliman medical necessity criteria to determine appropriate care.
3. Generated comprehensive reports and submitted them to state Health Care Authorities to maintain compliance.
4. Developed and maintained effective communication with healthcare providers to facilitate better treatment planning.
5. Trained and mentored staff on utilization review protocols and best practices.
6. Collaborated with interdisciplinary teams to optimize patient treatment plans and resource allocation.
7. Enhanced data collection methods to improve reporting accuracy and compliance tracking.

Experience

5-7 Years

Level

Executive

Education

BSN

Description :

1. Conduct comprehensive admission, continued stay, and discharge reviews for managed care and self-pay clients.
2. Foster positive relationships with referral sources and insurance providers to facilitate patient care.
3. Analyze individual member health plans, co-pays, and benefit criteria to ensure accurate service delivery.
4. Verify eligibility and document authorizations to maintain compliance with insurance policies.
5. Review medical documentation to substantiate diagnoses and treatment plans.
6. Maintain data integrity by entering patient demographics into clinical management systems.
7. Ensure compliance with Medicare regulations and address inquiries efficiently.

Experience

5-7 Years

Level

Executive

Education

BSN