Clinical Utilization Review Coordinator (LVN or BSW)
Austin , Texas
October 17, 2017
Performs activities under the direction of the Director of Case Management, coordinates essential compliance and operational process. Is responsible for identifying and obtaining required authorizations, facilitating authorizations for referrals, communicating with and accurately documenting communications with all payers in accordance with facility policies and procedures. The UM Clinical Coordinator will initiate/escalate denial management activities concurrently, will appeal and overturn insurance denials and serve as a liaison with the Patient Account Services (PAS) and others to minimize financial risk to the patient and facility. Provides overall coordination in the delivery of medical services and discharge planning for a specified patient population. Promotes a cooperative and supportive relationship as liaison with patient, family, facility staff, physicians, funding representatives and community agencies. Ensures continuity in the handoff of patient clinical information from the hospital to other involved healthcare entities.


Financial Assessment and Coordination
  • Maintains liaison with department director/Administrative director/case managers/ social workers and responds to their general questions assisting where possible.
  • Under the direction of the director and administrative director, gathers all essential data and prepares Improvement Quality report on a quarterly basis for Case Management.
  • Coordinates and prepares all reports for regulatory agencies & compliance needed in Case Management.
  • Communicates proactively and cooperatively with Patient Access, Patient Account Services (PAS) and Central Verification Office (CVO) personnel to ensure proper pre-certification and consistency of admissions status designation between physician order and EMR.
  • Communicates known changes to patient payer information and other relevant financial characteristics of coverage to appropriate admissions and/or billing personnel.
  • Proactively ensures that required clinical justification is provided to third party payers to obtain recertification for continued hospitalization and treatment and that transfer of this information, together with days approved and contact information is provided timely to the PAS and CVO via computerized insurance review documentation.
  • Work in collaboration with the Acute Case Management Team to facilitate utilization review and other case management functions
  • Actively seeks ways to control costs without compromising patient safety, quality of care or the services delivered
  • Maintains contact list for the department and communicates any changes to the appropriate parties
  • Retrieves information from voice mails and faxes related to case management activities in a timely manner
  • Distributes requests for information to the appropriate case manager
  • Performs accurate and timely documentation of all utilization review activities based on facility policy and procedure
  • Communicates effectively and professionally with physicians, hospital staff, and outside agencies
  • Works collaboratively with the Central Verification Office to ensure that all accounts are authorized
  • Performs follow up with third party payers to ensure that all information needed is communicated and all days of stay are authorized
  • Makes referrals to post acute providers as needed.
  • Performs other duties as assigned
  • Adheres to established policy and procedure and standards of care; escalates issues through the established Chain of Command timely
  • Demonstrates commitment to teamwork and cooperation
  • Works with the patient and family to identify alternate financial resources available to meet the cost of necessary post-discharge needs or to recommend alternate care options when necessary funding is unavailable
  • Proactively initiates expedited appeals process with payers and communicate with denials management regarding anticipated or verified denials and cooperate with denials management to provide additional clinical information for appeals.
Treatment Planning and Coordination of Services
  • Educates patient and family on case manager role and process for contacting the case manager for questions.
  • Coordinates the integration of social services/case management functions into the patient care, discharge and home planning processes with other hospital departments, external service organizations, agencies and healthcare facilities.
  • Ensures that patient tests are appropriate and necessary and are carried out within the established time frame and that results are promptly available.
  • Serves as a patient advocate by enhancing a collaborative relationship to maximize the patient's and family's ability to make informed decisions.
  • Refers to social work cases where patients and/or family would benefit from counseling required to complete complex discharge plans.
Utilization Review, Quality and Compliance Monitoring
  • Serves as liaison with Physician Performance Improvement (PPI) to ensure the reporting of quality indicators and care concerns.
  • Initiates delivery of notices of non-coverage as appropriate.
  • Communicates with treating physicians at regular intervals throughout hospitalization of the patient to develop an effective working relationship, while assisting physicians to maintain appropriate costs, utilization of resources, and discharge plans commensurate with the patient's available resources.
  • Ensures physician documentation supports medical necessity and LOC for each inpatient day, educates physicians by aggressively discussing additional documentation needs as identified or discharge plans and conferring with Case Management Director and Physician Advisor as needed for intervention.
  • Monitors and provides documentation of identified variance days for tracking and trending.
  • Stays current with education related to CMS and HCA billing compliance mandates monitors and ensures that facility is compliant.
  • Facilitates delivery of CMS discharge appeals rights communication to applicable Medicare patients within indicated time frame required by law.
  • Provides retrospective chart review for short stay inpatients under Medicare for medical necessity and level of care prior to billing.
Discharge Planning and Continuity of Care
  • Collaborates with interdisciplinary care team, service liaisons, patient and family in the assessment and coordination of discharge planning needs, delivery of post-discharge services and transition of the patient from an acute level of care to the discharge setting.
  • Facilitates delivery of Patient Information and Choice Letter to assure documentation of patient/family involvement with discharge planning and choice of post-discharge service providers.
  • Facilitates the ordering and delivery of specialized medical equipment, orthotics and prosthetics as ordered by the attending physician.
  • Facilitates delivery of Important Message to Medicare beneficiaries within 48 hours of discharge.
General Duties
  • Attends and actively participates in monthly staff meetings, and attends called departmental meetings when necessary.
  • Attends and participates in facility committees, employee forums and departmental meetings as requested.
  • Actively utilizes and complies with facility principles of good communication and customer service standards.
  • Maintains compliance with required licensure, ethics and compliance training, annual mandatory TB screening and mandatory education as required.
  • Prepares and presents in service and training programs as requested.

  • LVN with current state licensure, or BSW license
  • Three years' hospital experience in acute care setting, Case Management experience preferred
  • Certification in Case Management, Nursing, or Utilization Review preferred
  • Ability to establish and maintain collaborative and effective working relationships
  • Ability to communicate effectively in oral, written and electronic formats
  • Demonstrates analytical and critical thinking abilities with pro-active decision-making and negotiation skills
  • Demonstrates an ability to perform specific competencies as identified on the Case Management Competency

A little about us:
HCA is the nation’s leading private provider of healthcare services. Comprised of locally managed facilities which include 230,000 employees at over 160 hospitals, over 120 surgery centers and 100 urgent care facilities in 20 states and the United Kingdom

Know someone who would be interested in this job? Share it with your network.