Utilization Review/Management Coordinator - Level II

NYC Health + Hospitals/Metropolitan is the community hospital of choice for residents of East Harlem, northern Manhattan, and neighboring communities. The hospital provides culturally-sensitive care in a welcoming and hospitable setting, emphasizing primary care medicine and utilizing the latest advances in medical science. Metropolitan delivers high quality health services with compassion, dignity, and respect to all, without exception. Since its founding in 1875, the hospital has been affiliated with New York Medical College, representing the oldest partnership between a hospital and a private medical school in the United States. Metropolitan is a part of the NYC Health + Hospitals, the largest municipal hospital and health care system in the country.

At NYC Health + Hospitals, our mission is to deliver high quality care health services, without exception. Every employee takes a person-centered approach that exemplifies the ICARE values (Integrity, Compassion, Accountability, Respect, and Excellence) through empathic communication and partnerships between all persons.

Work Shifts

8:00 A.M - 4:00 P.M

Job Description
1. Performs admission, continued stay and discharge medical review using established criteria sets in an accurate and timely manner.
2. Screens cases for post discharge needs during admission review and communicates information to all disciplines as necessary and appropriate.
3. Ensures that documentation in the medical record supports the plan of care and justifies the admission and continued stay. Communicates with physicians as necessary.
4. Educates physicians regarding the appropriate InterQual/Milliman Guidelines to support the documentation of the plan of care.
5. Establishes a concurrent review cycle for each case on assigned clinical unit based on medical need/status, medical plan and resource utilization.
6. Identifies delays in service of treatment and actively interacts with disciplines to remove barriers to care.
7. Participates in Multidisciplinary Team Meetings to clarify issues, confirm plans of care, secure documentation required and facilitate concurrent action.
8. Communicates review findings to managed care organizations concurrently, to ensure compliance with contractual agreements according to departmental policy and procedure.
9. Alerts physicians of concurrent, uncertified day(s) in a timely manner and:
a. Arranges MD-to-MD (Peer-to-Peer) Reconsiderations timely as appropriate
b. Requests payor to send the resulting determination letter timely.
c. Follow-ups to ensure that the determination letter is received.
d. Reports any variances to the immediate supervisor and the denials Manager.
10. If a Peer-to-Peer Reconsideration is unsuccessful in reversing a concurrent denial, assists the physician in reassessing the patient's plan of care and possible treatment alternatives.

Minimum Qualifications
1. Graduate of an accredited Medical Program, including Foreign Medical Graduate; or
2. New York State Professional Nursing Licensure (R.N.); and
3. Two (2) years of experience in a hospital clinical setting in a capacity which provides thorough
understanding of medical diagnosis, symptoms and treatment concepts; or one year of experience in
Utilization/Quality Management; or
4. A satisfactory equivalent.

NYC Health and Hospitals offers a competitive benefits package that includes:

• Comprehensive Health Benefits for employees hired to work 20+ hrs. per week
• Retirement Savings and Pension Plans
• Loan Forgiveness Programs for eligible employees
• Paid Holidays and Vacation in accordance with employees' Collectively bargained contracts
• College tuition discounts and professional development opportunities
• Multiple employee discounts programs