Utilization Review/Management Coordinator - LI

Woodhull Medical and Mental Health Center is attuned to the healthcare issues that matter to the people of North Brooklyn. Woodhull focuses on preventing disease and promoting healthy lifestyles by reaching out to the community at various locations.

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

9:00 A.M - 5:00 P.M

Job Description

PURPOSE OF POSITION

This position is needed in order to positively affect the revenue cycle by assessing and evaluating inpatient admissions to assure medical necessity is met during the period of hospitalization. The UR/CM functions are crucial to the coordination of care/services to enhance patient throughput/flow.

AREAS OF RESPONSIBILITIES

Analyzes the medical records, labs, imaging, and medication records to abstract pertinent clinical information to determine the appropriateness/medical necessity for admission and continued stay throughout the period of hospitalization.

SUMMARY OF DUTIES AND RESPONSIBILITIES

Abstracts pertinent clinical information from the medical record to determine the appropriateness (medical necessity) for admission/continued stay.
- Responsible for entering the clinical information in EPIC within a timely manner.
- Facilitates the delivery of care and services on the patient care units by:
• Participating in ICP rounds
• Assisting other disciplines in order to develop a plan
• Ensuring that discharge planning is initiated on a timely bases by working collaboratively with the Social Worker in order to establish a safe plan that meets the patient's needs.
- Coordinating services with the managed care companies in obtaining authorization for required services
- Providing coverage and certification information to the other disciplines, as needed
- Determining the current level of care based upon established guidelines
- Takes appropriate and immediate action for all deviations that do not meet criteria or lack justification for in-patient care.
- Assists the physicians to document the intensity and the severity of illness. Based upon documentation, recommends and assigns appropriate level of care.
- Completes and assign Accommodation codes for patients on ALOC in EPIC
- Evaluates the planned interventions as they relate to the needs of the patients, monitors the patient's progress toward setting the goals and makes appropriate documentation, as needed.
- Provides timely concurrent clinical reviews to the third-party payers (upon request), obtains certification status from the plan, and reviews daily "End of Day Reports" provided by the managed care companies and enters the payer's decision into EPIC.
- Works collaboratively with Patient Accounts regarding the patient's insurance and any coverage issues.
- Maintains appropriate documentation in EPICs to support review activities as per departmental policies and procedures.
- Informs the department of all adverse determinations received for adequate follow up by sending an email to the Supervisor and the Appeal team.
- For those patients that have managed care notifies managed care of patients requiring transfer to another facility for services not performed at Woodhull in order to obtain authorization for transfer.
- Conducts focused reviews, as assigned, collects data, prepares, and submits timely and accurate reports.
- Assures completeness of medical record for submission to the appropriate Quality Improvement Organization (IPRO or Livanta) for those patient's appealing their discharge.
- Notifies the Physician Advisor of cases that do not meet criteria on a timely bases.
- Maintains competency through attending seminars related to job topics (i.e. Infection Control, HIPPA, Health Care, Discharge Planning, third party regulations, etc.)

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