Utilization Review Coordinator - Philadelphia, United States - Wills Eye Hospital

Description

EOE Statement We are an equal employment opportunity employer.

All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, national origin, disability status, protected veteran status or any other characteristic protected by law.

About the Organization Wills Eye Hospital, located in Philadelphia, Pennsylvania, is a global leader in the treatment of eye disease.

Established in 1832 as the America's first eye hospital, we are one of the world's premier eye care facilities and the #2 best hospital in the nation for ophthalmology as ranked by U.S.

News & World Report.

Our clinical expertise, state-of-the-art diagnostic testing and advanced surgical capabilities make Wills Eye a worldwide referral center where more than 250,000 patients are treated annually.

From common eye problems to rare sight-threatening diseases, Wills Eye provides general eye care and comprehensive ophthalmic specialty services that attract patients throughout the Philadelphia metropolitan area, across the country and around the world.

Today, we continue to shape the science and medicine of ophthalmology, thanks to our talented, skilled physicians and staff who are dedicated to improving and preserving sight.

Description Primary Function:

Under CNO supervision, the Utilization Coordinator provides utilization review, Amkai chart surveillance and denials management for the inpatient case load.

This role utilizes the nationally recognized Milliman Care Guidelines/Criteria to assess the patient's need for inpatient care as well as determining the appropriate level of care.

The Utilization Coordinator interfaces with the medical team, physician office staff, other staff members as well as payers.


Essential Duties and Responsibilities:

Obtains the information necessary to assess a patient's clinical condition, identify ongoing clinical care needs and ensure that the patients receive services in the setting that best meets their needs.

Determines the patient's insurance coverage and eligibility to facilitate completion of the utilization review process using payer specific criteria. Uses MCG guidelines to establish medical necessity and determine inpatient versus observation status of the patient. Utilizes clinical skills to provide and facilitate utilization review, continued stay reviews and utilization management of inpatient cases. Reviews assigned ICD- 10 codes and CPT codes for appropriate reimbursement. Reviews prior authorization / Observation stay requests to determine appropriate care and setting.

Reviews all inpatient Amkai chart records to ensure accuracy and completeness; monitors and reports trends of inappropriate utilization of resources or quality issues to the Medical Director(s).

Collaborates with various staff within the provider's network as well as functioning as a resource to the clinical team regarding authorization policies, approval criteria, practice guidelines, and alternate treatment options if admission is not an indication for a patient.

Remains current on clinical practice and protocols that affect clinical reimbursement. Participates in meetings and committees related to this role and represents the department as necessary. Collaborates with billing office staff to review denied claims and assists with the appeals process. Performs other related duties as assigned.


Position Requirements Qualifications Educational requirements:
Bachelors of Nursing Degree or equivalent required Licensure: Active Pennsylvania State Nursing License required Basic Life Support (BLS)

Certification requiredExperience:
Minimum of 2 years' experience as clinical nurse in an acute care/hospital setting.

Experience with Prior Authorization and Utilization Review Experience using Milliman or InterQual criteria for medical necessity, setting and level of care, and concurrent patient management Must be organized, detailed oriented, and capable of handling multiple issues.

Category Nurse InformaticsFull-Time/Part-Time Full-TimePosition Project ManagerNumber of Openings 1Exempt/Non-Exempt ExemptLocation Wills Eye HospitalThis position is currently accepting applications.