A Utilization Review Coordinator will ensure that patients in the healthcare facilities receive correct treatment at the appropriate time. The normal duties that are mentioned on the Utilization Review Coordinator Resume include the following – reviewing case files of patients after considered factors like admission time, duration of stay and discharge plans; ensuring the patients are ready for discharge, abstracting data from medical charts and records; resolving any sort of errors or issues; auditing medical records, justifying the length of stay and documenting regarding patient’s continued hospitalization.
Candidates for this role must have a good understanding of medical terminologies, and stay tuned with latest developments in the field; they should possess knowledge of reviews such as MAC, KEPRO, and RAC; strong observing skills and the ability to monitor safety plans are also needed. In addition to a bachelor’s degree, many positions also require candidates to have an RN qualification.
Summary : Utilizing excellent organizational and time management skills. Uses sound judgment, and has the ability to work collaboratively with professions and professionals having various backgrounds, including clinicians, nurses, and physicians in large corporations. Excellent analytical and writing skills, coupled with good business acumen.
Skills : Retail Sales, Call Center Customer Care, Case Management, Direct Care, Therapeutic Care.
Description :
Analyzes and reviews for Inpatient, Residential, Intensive Outpatient and Moderate Intensive Outpatient patients in the treatment program.
Works with the physician and clinicians to maintain the appropriate level and quality of care.
Provides proactive management of acutely and chronically ill patients with the objective of improving quality outcomes and decreasing costs.
Provides feedback to treating physicians regarding a member's discharge plans and available covered services including identifying alternative levels of care that may be covered.
Implements workflow that presents facility-patient status updates and addresses barriers to discharge at regularly held concurrent review rounds.
Addresses care and documentation issues with the Nurse Manager and Director as appropriate for training and problem resolution.
Coordinates an interdisciplinary approach to support continuity of care, authorizations for covered services as needed for members.
Experience
7-10 Years
Level
Management
Education
Diploma
Utilization Review Coordinator ll Resume
Headline : Empathetic and skilled Mental Health Technician, providing mental health care to children, patients, and returning veterans. Enthusiastic personality with the ability to work with the members of the interdisciplinary team.
Skills : Microsoft Office, Microsoft Excel, Microsoft Word, Powerpoint.
Description :
Utilizes pre-approved criteria and guidelines to validate the medical necessity of continued stay and appropriateness of treatment and discharge planning
Performs on-site and/or telephonic concurrent review of acute and all services following the plans authorization guidelines.
Predicts and plans for patient's needs from pre-admission, through acute and collaboration with the member and providers.
Coordinates with appropriate discharge planning with the interdisciplinary health care team to coordinate timely discharge.
Tracks and reports trends of inappropriate utilization of resources or quality issues to the Medical Director.
Functions as a major contributor as it relates to discharge planning and readmission reduction strategies.
Responsible for assessing patient admission including specific criteria that determined the length of stay, care, etc.
Experience
5-7 Years
Level
Executive
Education
Diploma
Utilization Review Coordinator l Resume
Objective : Completed a Master's Degree in Counseling Psychology and a specialization in Couple and Family Therapy. Licensed Mental Health Counselor. Completed Chemical Dependency Certificate. Experience working as a therapist at a community mental health clinic.
Responsible for coordinating cases for precertification and prior authorization review.
Manages incoming calls or faxes, including triage, opening of cases and authorizing sessions.
Responsible for the identification and data entry of referral requests into the UM system in accordance with the plan certificate.
Responds to telephone and written inquiries from clients, providers and in-house departments.
Conducts clinical screening process, authorizes an initial set of sessions to provider, checks benefits for facility-based treatment.
Develops and maintains positive customer relations and ensure customer requests are handled appropriately and in a timely manner.
Precepts new associate, and thoroughly assist them with learning day to day job functions.
Experience
2-5 Years
Level
Junior
Education
Diploma
Asst. Utilization Review Coordinator Resume
Headline : To secure a position as a valuable member of your managerial team that will leverage skills, achievements, and ability to lead personnel in a direction that provides and promotes superior service.
Skills : Word, Excel, Powerpoint, Team Leadership, Teamwork, Customer Service, Access.
Description :
Analyzed patient records to determine the legitimacy od Admission, treatment, and length of stay in the health care facility.
Reviewed applicants for patient admission and approved admission with the case facility utilization review committee for review and to meet admission standards.
Compared inpatient medical records to establish criteria and confers with medical and nursing personnel and other professional staff to treatment and length of stay.
Abstracted data from records and maintained statistics Determined patient's review date according to established diagnostic criteria.
Assisted the review committee in planning and holding federally mandated quality assurance reviews.
Predicted and planned for patient's needs from pre-admission, through acute and sub-acute care and post-discharge, in collaboration with the member and providers.
Coordinated with appropriate discharge planning with the interdisciplinary health care team to coordinate timely discharge.
Experience
5-7 Years
Level
Executive
Education
Diploma
Associate. Utilization Review Coordinator Resume
Headline : A responsible challenging position within your company that will allow learning new techniques and skills while utilizing previous experiences and to be part of the growth of the organization.
Skills : Attention To Detail, Strong Organizational Skills, and MS Office, Outlook, Office: Word, Powerpoint
Description :
Ensured documentation of authorization, last day covered and days denied is in the system.
Participated in treatment planning sessions as a representative of the patient's benefit parameters.
Collaborated with Assessment Teams, Billing and other administrative pre-certifications, authorizations, and denials.
Coordinated retrospective reviews and appeal process for denial of service by the external payor.
Ensured that proper treatment and follow up care was being provided to the client and all areas of support.
Negotiated reimbursement as needed on per case basis following guidelines outlined by the Administrator and Supervisor.
Assumed responsibility for current knowledge of Joint Commission and documentation for treatment, and discharge.
Experience
5-7 Years
Level
Management
Education
Diploma
Sr. Utilization Review Coordinator Resume
Headline : Experienced registered nurse with over years of varied clinical experience including utilization review implementation and management, commercial and Medicare appeals, documentation improvement, medical record review, behavioral acute care, and nursing management.
Skills : Program Development, Proposal Writing, Teamwork, Customer Service, Access.
Description :
Clarifies unclear treatment plan requests by contacting the requesting provider's office.
Communicates and works with claim examiners as needed to provide clinical information to resolve issues.
Responds to telephone inquiries proving accurate information and triage as necessary.
Enters demographics and Utilization Review information into claims or clinical management system, maintains data integrity.
Obtains all necessary information required for processing from internal and external sources per policies and procedures.
Distributes incoming and outgoing correspondence, uploads review documents into the paperless system as necessary.
Assists the review committee in planning and holding federally mandated quality assurance reviews.
Experience
5-7 Years
Level
Executive
Education
Diploma
Utilization Review Coordinator/Consultant Resume
Summary : Able to provide direct care to children and adults with metal health and or substance abuse diagnosis. Work experience includes daily customer care services, previous call center experience.
Analyzed all patient records and current treatment plans to determine medical necessity.
Complied with the federal government and managed care reimbursement policies.
Directed liaison between the member, provider, Physical Therapy Network and regional union benefit reps for all questions, concerns, and problems.
Handled all claim issues, denials and balance billing against contractual agreements.
Coordinated single-payer agreements for out of network care.
Entered demographics and Utilization Review information into claims or maintains data integrity.
Obtained all necessary information required for processing from internal and external sources per policies and procedures.
Experience
7-10 Years
Level
Management
Education
Diploma
Utilization Review Coordinator/Specialist Resume
Headline : Team building of Relationship Based Care at Pine Rest Christian Mental Health Services. Maintain a strong reputation for achieving high levels of patient satisfaction. patient care and overall improvement of the mind, body, and spirit of the community.
Summary : A social worker with experience, looking for meaningful employment in a social service setting within skilled nursing or healthcare, children's welfare, law enforcement or another area.
Skills : Customer Service, Customer Relationship Management, Problem Resolution.
Description :
Provided timely reviews of appropriateness of admission, duration of inpatient stays, and professional services rendered.
Performed concurrent chart review, including admission reviews, stay reviews, and discharge reviews.
Assisted the medical staff in initiating discharge planning and developed the hospital-specific length of stay norms.
Acted as liaison to insurance companies to provide information pertaining to the patient's progress.
Assured compliance with Medicare regulations and responds to telephone inquiries providing accurate information and triage as necessary.
Reviewed documentation, including medical history, physical examinations, to ensure support of the diagnosis.
Entered demographics and information into a claim or clinical management system maintaining data integrity.
Experience
10+ Years
Level
Executive
Education
Diploma
Utilization Review Coordinator/Analyst Resume
Summary : Nursing Professional with many years of nursing experience. Accomplished in a variety of settings, including Utilization Review, Program Manager, Department Director, and Interim Service Director. Detail-oriented, well organized, and excellent communication skills.
Skills : Case Management, Counseling, Microsoft Office, Microsoft Excel, Microsoft PowerPoint.
Description :
Responds to telephone inquiries providing accurate information and triage as necessary.
Enters demographics and information into claims or clinical management system - maintaining data integrity.
Obtains all necessary info required for utilization review processing from internal external sources per policies and procedures.
Distributes incoming correspondence, faxes, and mail and uploads review documents into the paperless system as necessary.
Assures compliance with Medicare regulations and responds to telephone inquiries and triage as necessary.
Reviews documentation, including medical history, physical examinations, support of the diagnosis.
Enters demographics and information into a claim or clinical management system maintaining data integrity.
Experience
10+ Years
Level
Senior
Education
Diploma
Utilization Review Coordinator/Executive Resume
Headline : Able to utilize over seven years of experience in the mental health field to provide effective practice to adults, adolescents, and children. able to pull from a strengths-based perspective. Knowledgable of utilization review, Milliman medical necessity criteria, as well as case management.
Skills : Motivational Interview Training And Problem Solving Therapy Training, Microsoft Word.
Description :
Specialized in completing insurance reviews with private insurance companies as well as Medicaid.
Assured compliance with Medicare regulations and responds to telephone inquiries providing accurate information and triage as necessary.
Reviewed case records and assessed for Milliman's medical necessity criteria on a daily basis.
Completed report through Internet template and faxed report to state Health Care Authority.
Assured compliance with Medicare regulations and responds to telephone inquiries providing accurate information and triage as necessary.
Reviewed documentation, including medical history, physical examinations, and diagnostic studies to ensure support of the diagnosis.
Entered demographics and information into a claim or clinical management system maintaining data integrity.
Experience
5-7 Years
Level
Executive
Education
Diploma
Utilization Review Coordinator Resume
Headline : Seeking a position in social services or mental health that can contribute to a broad range of experience in case management, administration, advocacy, and counseling. clients well being and effective in developing and implementing programs in a timely fashion.
Skills : , Customer Service, Customer Relationship Management, Problem Resolution,
Description :
Performs admission, continued stay and discharge reviews on all managed care, private insurance, and self-pay clients.
Maintains positive relationships with referral sources and insurance companies.
Researches and substantiates individual member's health plan benefits, co-pays, and benefit criteria.
Checks eligibility when entering authorizations, documenting, and submitting eligibility requests.
Reviews documentation, including medical history, physical examinations, to ensure support of the diagnosis.
Enters demographics and information into a claim or clinical management system maintaining data integrity.
Assures compliance with Medicare regulations and responds to telephone inquiries and triage as necessary.
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