Utilization Review Coordinator jobs in South Carolina

Utilization Review Coordinator conducts utilization reviews to determine if patients are receiving care appropriate to illness or condition. Monitors patient charts and records to evaluate care concurrent with the patients treatment. Being a Utilization Review Coordinator reviews treatment plans and status of approvals from insurers. Collects and complies data as required and according to applicable policies and regulations. Additionally, Utilization Review Coordinator consults with physicians as needed. May require a bachelor's degree. Typically reports to a supervisor. Typically requires Registered Nurse(RN). The Utilization Review Coordinator contributes to moderately complex aspects of a project. Work is generally independent and collaborative in nature. To be a Utilization Review Coordinator typically requires 4 to 7 years of related experience. (Copyright 2024 Salary.com)

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Utilization review specialist
  • Lexington Medical Center
  • West Columbia, SC FULL_TIME
  • Utilization Management Dept.

    Full Time

    AM Shift

    7 : 30-4 : 00

    Consistently named best hospital, Lexington Medical Center dedicates itself to providing quality health services that meet the needs of its communities.

    Ranked #2 in the state and #1 in the Columbia metro area by U.S. News & World Report, Lexington Medical Center is the only hospital named one of the Best Places to Work in South Carolina.

    The 607-bed teaching hospital anchors a health care network that includes five community medical centers and employs more than 8,000 health care professionals.

    The network includes a cardiovascular program recognized by the American College of Cardiology as South Carolina's first HeartCARE CenterTM and an accredited Cancer Center of Excellence affiliated with MUSC Hollings Cancer Center for research and education.

    The network also features an occupational health center, the largest skilled nursing facility in the Carolinas, an Alzheimer's care center and nearly 80 physician practices.

    Its postgraduate medical education programs include family medicine and transitional year.

    Job Summary

    Performs admission and concurrent stay medical record review to determine appropriateness of admission, continued stay, and setting.

    Follows patient throughout hospitalization collaborating with attending physician and other health care providers. Communicates with third party payors to obtain authorization.

    Contributes to appropriate throughput and length of stay. Assists with denial management. Reviews physician medical record documentation and consults with physicians regarding completeness.

    Minimum Qualifications

    Minimum Education : ADN, Diploma Nursing Degree, or Bachelor of Science in Nursing

    Minimum Years of Experience : 3 Years of experience in an acute care hospital setting

    Substitutable Education & Experience : None.

    Required Certifications / Licensure : Registered Nurse currently licensed in the State of South Carolina

    Required Training : None.

    Essential Functions

    Works in a cooperative manner, which fosters favorable relations between employees and patients, patients' families, visitors, fellow employees, and the medical staff.

    Accepts chain of command, supervision, and constructive criticism.

    • Exhibits commitment and pride through personal example by positively speaking about LMC, the department, employees and guests.
    • Contributes to teamwork and creates harmonious, effective and positive working relationships with others.
    • Respects, understands, and responds with sensitivity to employees and guests by treating others as one would wish to be treated.
    • Resolves conflicts and problems-solves by remaining calm when confronted, attempting to identify solutions or referring person to appropriate authority and attempting to deliver more than is expected.
    • Exhibits telephone courtesy by :
    • Answering promptly with name and department.
    • Speaking with pleasant tone while focusing on caller.
    • Transferring calls correctly and promptly.
    • Attending to calls on hold in a timely manner.
    • Maintains confidentiality by :
    • Discouraging gossip.
    • Using discretion when discussing patient, work, or LMC-related information with others.
    • Utilizes the service recovery process to resolve complaints (GIFT).
    • Demonstrates competence in providing duties within role.
    • Demonstrates competence to provide developmentally appropriate planning / review for patients of all age groups.
    • Identifies need for professional growth and seeks appropriate professional development opportunities attaining a minimum of 15 hours of continuing education in topics related to the role annually.
    • Serves as role model for other members of the health care team.
    • Demonstrates receptiveness to change and flexibility in meeting department needs.
    • Assists in orientation and training of staff.
    • Performs admission and continued stay medical record review to gather information to support medical necessity of the admission and communicate with third party payors.
    • Performs timely review of admissions utilizing InterQual criteria to assess for appropriate level of care assignment. Reviews both inpatient admissions and patients placed in Observation.
    • Incorporates applicable governmental regulatory guidelines in effect for Medicare and / or Medicaid admissions.
    • Submits clinical data to third party payors and documents authorization in electronic medical record system.
    • Performs continued stay reviews based on intensity of service, clinical response to care, expected length of stay and readiness for discharge, or at intervals which correspond to authorized days.
    • Refers Observation or Inpatient admissions that lack documented medical necessity for the stay to the Physician Advisor and completes any needed follow through to ensure correct level of care and billing based on the Physician Advisor's determination.
    • Documents pertinent clinical data on worksheets.
    • Ensures regulatory compliance and revenue integrity utilizing appropriate billing policies.
    • Certifies Medicare admission utilizing established admission screening criteria.

    Duties & Responsibilities

    • Applies appropriate condition codes and modifiers in electronic medical record system to communicate accurate claims information for billing.
    • Documents denial information in electronic medical record system including attempts at resolution / overturning of the denial.
    • Provides all payor communication to be scanned into the system for use in appeals.
    • Maintains good working relationships with other departments within the revenue cycle.
    • Conveys and receives information efficiently to and from third party payors, physicians, patients / families, physician practices, other members of the health care team, and other external agencies.
    • Respects patient confidentiality and uses discretion in all interactions regarding patient protected health information.
    • Consults with attending physician when documentation in the medical record does not support admission or continued stay and seeks to ensure completeness of all clinical documentation.
    • Functions as liaison between the Physician Advisor and the attending physician.
    • Serves as a resource to physicians, patients, physician practices, and other members of the health care team regarding issues related to patient classification and reimbursement.
    • Issues letters of non-coverage in cases where the admission or continued stay is not certified, as necessary.
    • Ensures patient / family notification of Observation status and documents in electronic medical record.
    • Communicates insurance authorization information to physician's office as requested.
    • Communicates with case management triad regarding reimbursement issues.
    • Uses appropriate channels for reporting progress or concerns.
    • Participates in making appropriate and efficient discharge plans for patients on assigned areas.
    • Consults with members of the health care team effectively and efficiently regarding patient discharge plans.
    • Manages inpatient Medicare discharge expedited appeals process through the QIO.
    • Notifies attending physician and other members of the health care team of inappropriate admissions, denials, end of authorized days, or other factors that have a reimbursement impact.
    • Consults Physician Advisor in cases where patient demonstrates readiness for discharge, but there is no documented intent to discharge.
    • Identifies and documents potentially avoidable days in electronic medical record system.
    • Assist Social Work staff to coordinate / obtain authorization for post acute services as needed.
    • Identifies opportunities for improvement and coordinates / participates in the development and implementation of action plans to make improvements.
    • Participates in unit discharge planning activities and in interdisciplinary patient care conferences.
    • Indentifies abnormal patterns of utilization and refers to Manager / Director.
    • Recommends changes to system / processes to eliminate identified problems.
    • Represents department on various committees / taskforces.
    • Adapts to change in timely and positive manner.
    • Strives to meet department and hospital goals.
    • Performs all other duties as assigned by authorized personnel or as required in an emergency (e.g., fire or disaster).

    We are committed to offering quality, cost-effective benefits choices for our employees and their families :

    • Day ONE medical, dental and life insurance benefits
    • Health care and dependent care flexible spending accounts (FSAs)
    • Employees are eligible for enrollment into the 403(b) match plan day one. LHI matches dollar for dollar up to 6%.
    • Employer paid life insurance equal to 1x salary
    • Employee may elect supplemental life insurance with low cost premiums up to 3x salary
    • Adoption assistance
    • LHI provides its full-time employees employer paid short-term disability and long-term disability coverage after 90 days of eligible employment
    • Tuition reimbursement
    • Student loan forgiveness

    Equal Opportunity Employer

    It is the policy of LMC to provide equal opportunity of employment for all individuals, and to remain compliant with applicable state and federal laws and regulations.

    LMC strives to provide a discrimination-free environment, and to recruit, select, on-board, and employ all employees without regard to race, color, religion, sex, age, disability, national origin, veteran status, or pregnancy, childbirth, or related medical conditions, including but not limited to, lactation.

    Last updated : 2024-03-25

  • 1 Day Ago

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Utilization Review Nurse/Case Manager
  • Health Partners Management Group
  • Charleston, SC FULL_TIME
  • SUMMARY: This position will actively and retrospectively review medical cases to confirm that patient receive appropriate care and ensures cost effectiveness of health care services. Utilization manag...
  • 13 Days Ago

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Utilization Review Specialist - Part-time
  • Acadia Behavioral Health (Pioneer Behavioral Health)
  • Lancaster, SC PART_TIME
  • Employment Type: Part-Time Hours Per Week: 1 The Utilization Review Specialist at Rebound Behavioral Health will be responsible for conducting initial and concurrent reviews while reviewing clinical d...
  • 28 Days Ago

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Utilization Review Specialist - Part-time
  • Rebound Behavioral Health
  • Lancaster, SC PART_TIME
  • The Utilization Review Specialist at Rebound Behavioral Health will be responsible for conducting initial and concurrent reviews while reviewing clinical documentation for the stay of the patient. Reb...
  • 1 Month Ago

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Clinical Monitoring and Review Coordinator
  • AIS Healthcare Career Center
  • Greenville, SC FULL_TIME
  • This in office position is a quality based, detail oriented position is located in Greenville, South Carolina. AIS Healthcare is the leading provider of Targeted Drug Delivery (TDD) and Infusion Care....
  • 24 Days Ago

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Clinical Monitoring and Review Coordinator
  • AIS Healthcare
  • Greenville, SC FULL_TIME
  • This in office position is a quality based, detail oriented position is located in Greenville, South Carolina. AIS Healthcare is the leading provider of Targeted Drug Delivery (TDD) and Infusion Care....
  • 9 Days Ago

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Utilization Review Coordinator (Part-time, Not Remote) Opioid Treatment Program
  • UHS
  • Greenwood, IN
  • Responsibilities WHO WE ARE Valle Vista Health System (a UHS affiliated facility) is a 132-bed, acute care psychiatric h...
  • 3/28/2024 12:00:00 AM

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Utilization Review Coordinator
  • TheraMatrix
  • Pontiac, MI
  • Job Description Job Description Duties and Responsibilities: Initial authorizations of outpatient physical therapy servi...
  • 3/28/2024 12:00:00 AM

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Utilities Supervisor
  • System One Holdings, LLC
  • Hightstown, NJ
  • SUMMARY Perform periodic maintenance of utilities equipment. Responsible for HVAC, water system and Boiler area day to d...
  • 3/28/2024 12:00:00 AM

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Utilization Reviewer Coordinator
  • NeuroBehavioral Hospitals
  • West Palm Beach, FL
  • You Matter: Make a difference every day in the lives of the underserved Join a mission driven organization with a people...
  • 3/26/2024 12:00:00 AM

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Utilization Review Coordinator / Case Management / PRN
  • Christus Health
  • Santa fe, NM
  • Description POSITION SUMMARY: Registered Nurse uses approved screening criteria (MCG®/CMS Inpatient List) to determine t...
  • 3/25/2024 12:00:00 AM

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TEMP FT UTILIZATION REVIEW COORDINATOR
  • UHS
  • Jacksonville, FL
  • Responsibilities Universal Health Services, Inc. , one of the nation's largest and most respected providers of hospital ...
  • 3/25/2024 12:00:00 AM

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Utility Coordinator
  • KEITH
  • Miami, FL
  • Utility Coordinator - Miami, FL KEITH is seeking a Utility Coordinator to join our Miami, FL office to strengthen our gr...
  • 3/25/2024 12:00:00 AM

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Refrigeration/Utilities Supervisor
  • The Judge Group
  • New Castle, IN
  • Hiring Company: Boar's Head Provisions Co., Inc.Overview:Reporting directly to the Facility Manager, this position is re...
  • 3/24/2024 12:00:00 AM

South Carolina (/ˌkærəˈlaɪnə/ (listen)) is a state in the Southeastern United States and the easternmost of the Deep South. It is bordered to the north by North Carolina, to the southeast by the Atlantic Ocean, and to the southwest by Georgia across the Savannah River. South Carolina became the eighth state to ratify the U.S. Constitution on May 23, 1788. South Carolina became the first state to vote in favor of secession from the Union on December 20, 1860. After the American Civil War, it was readmitted into the United States on June 25, 1868. South Carolina is the 40th most extensive and 23...
Source: Wikipedia (as of 04/11/2019). Read more from Wikipedia
Income Estimation for Utilization Review Coordinator jobs
$76,161 to $94,337

Utilization Review Coordinator in Long Beach, CA
The Utilization Review Coordinator contributes to moderately complex aspects of a project.
January 05, 2020
Utilization Review Coordinator in Gary, IN
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.
December 29, 2019
Utilization Review Coordinator in Chicago, IL
Including requirements, responsibilities, statistics, industries, similar jobs and job openings for Utilization Review Coordinator.
December 30, 2019