[Hiring] Utilization Review Coordinator @Health Plans Inc

Role Description

The UM Review Coordinator performs review of clinical information submitted to determine medical necessity, appropriate level of care and length of stay, based on standardized clinical criteria. The UM Review Coordinator renders positive determinations for cases that meet the criteria and refers all other cases for physician peer review (“Peer Reviewer”).

In this role, you’ll also:

• Gather relevant clinical information from appropriate health care providers
• Confirm medical necessity for selected procedures and services based on application of standardized clinical criteria to clinical information submitted; if a positive determination cannot be made based on the criteria, refer case to Peer Reviewer
• Conduct utilization management of appropriate level of care and length of stay using standardized clinical criteria
• Consult with Peer Reviewers when a positive determination cannot be made based on the standardized criteria or peer consult is needed to determine appropriateness of care beyond the standardized criteria
• Provide timely case screening to identify case management needs and generate appropriate referrals to Case Management or other appropriate clinical programs
• Ensure timely follow up on outstanding utilization management issues and inquiries
• Collaborate with health care providers to identify discharge needs in order to facilitate timely discharge to an appropriate level of care, with referral to Case Management as appropriate
• Communicate with providers and other health care professionals regarding the Utilization Management process
• Ensure case documentation follows policy and procedure
• Proactively manage professional growth by collaborating with Manager to identify as appropriate
• Demonstrate consistent and appropriate application of standardized criteria for purposes of interrater reliability
• Maintain satisfactory quality audit scores
• Manage work time and caseload efficiently
• Adherence to HIPAA policies and procedures

Qualifications

• A minimum of three years of experience in an acute care clinical setting.
• Active, current and unrestricted professional licensure as an RN (Registered Nurse) or LPN (Licensed Practical Nurse) in Massachusetts, Maine, New Hampshire or state of residency
• Proficient in Microsoft Office, including Word, Excel, Outlook and PowerPoint

Benefits

• Medical, Dental and Vision and Prescription Drug Coverage
• Fitness Reimbursement Benefit
• Employee Assistance Program
• Flexible Spending Account & Health Savings Account
• 401(k) and Quarterly Bonuses
• Generous Paid-Time Off & Volunteering Opportunities
• Educational Assistance & Professional Development Opportunities

Company Description

HPI is unique. A respected industry leader that’s been serving customers for over 44 years, we’re known for our innovation and adaptability. Our experience has given us our expertise, but our forward-thinking, entrepreneurial spirit has given us our strong reputation. As a third-party administrator, we offer a suite of health and benefit solutions to employers.

Our commitment extends beyond our clients to our own employees. We foster a supportive and inclusive work environment where innovation thrives. By investing in our team’s growth and well-being, we ensure they are equipped to provide exceptional service.