Utilization Review Coordinator Duties
The utilization review process assists medical facilities with staying in compliance with process, procedures and guidelines that ensure facilities stay within budget and effectively limit errors in patient care, payment and costly negligence. Coordinators oversee the utilization review process taking on many tasks including data collection, analysis, consulting and reporting.
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What is Utilization Review?
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Utilization review is a process designed to ensure a medical facility provides service that meet treatment guidelines deemed appropriate for those services. The review process can be used for inpatient or outpatient services and is performed to manage and make positive improvement to insurance claims for medical facilities like hospitals. The utilization review process is managed by the coordinator who typically possesses a bachelor's degree in nursing or is a practicing registered nurse (RN).
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Utilization Review Process Administration
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The utilization review coordinator monitors and assesses the use of hospital services by administering utilization review procedures required under Federal, State and County regulations. Following guidelines established in the medical facility's Utilization Review plan, the coordinator outlines the steps in the process then ensures each task defined in the review process is followed to completion.
Utilization Management Consultant
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The coordinator serves as a consultant in the utilization review process, analyzing insurance, government and accrediting agency standards to determine the review criteria for hospital processes including admissions, treatment and length of patient visit. For admissions, the coordinator will review applications for patient admission and approve or direct to a faculty committee for review. Coordinators review inpatient medical records confirming treatment and length of stay with medical staff and nursing personnel if required. Finally, the coordinator takes data from records and manages statistics used to establish diagnostic criteria and assist review committees in planning and holding federally mandated quality assurance reviews.
Quality Assurance
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The coordinator in utilization review also works as a quality assurance professional as their duties are designed to increase hospital efficiency. To do so, coordinators review all discharge paperwork for patients leaving the facility as final step in ensuring all records, process and steps have been completed. For high risk patients or any patient requiring discharge planning assistance, the coordinators refer cases to the Social Work department and then follow up with that department to confirm timely intervention and documentation is collected as the discharge plan is established. For patients awaiting entry to a skilled nursing facility, the coordinator tracks the forms and paperwork process, working with the Long Term Case Coordinator in the Social Work department. For home care discharge plans, the coordinator identifies the appropriate home care agency to arrange for nurse aide assistance and equipment.
Payment and Reporting
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Coordinators also review the process of service payment in coordination with the Financial Counselor at the medical facility. They oversee the paperwork process in working with third party payers like insurance agencies documenting all contact, conversations and payment requests. Finally, coordinators compile all of their data, trends, statistics and issues into a report that is shared regularly with the Utilization Review committee within the medical facility to report issues, trends and to suggest improvement methods for any problem areas identified in the reporting process.
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- Photo Credit Image by Flickr.com, courtesy of The Consumerist
