Utilization Review and Case Manager

Job Title: Utilization Review Coordinator
Department: Med/Surg

FLSA Classification: Non-Exempt - Eligible for Overtime
Employment Status: Full-Time/Part-Time/PRN

Location: Harrison County Community Hospital (HCCH)
Reports to: Director of Nursing

Job Summary/Objective:
The Utilization Review Coordinator supports a comprehensive, ongoing, and integrated review system that identifies problems and opportunities to improve care and services related to quality, risk, or utilization. This role ensures compliance with regulatory requirements, promotes efficient resource use, and enhances the quality of patient care delivery. A state-licensed registered nurse is required for this position.

Essential Functions/Duties/Responsibilities:

• Conduct concurrent and retrospective reviews of patient records to ensure appropriate utilization of services and adherence to evidence-based care guidelines.
• Evaluate medical necessity, length of stay, and level of care in collaboration with healthcare providers and insurance companies.
• Identify opportunities to improve care delivery and implement strategies for quality enhancement.
• Review and verify documentation for accuracy, completeness, and compliance with regulatory and accreditation standards.
• Collaborate with multidisciplinary teams to address barriers to efficient patient care and discharge planning.
• Provide education to staff regarding utilization review processes, documentation standards, and best practices.
• Prepare and submit required reports and data analysis for internal and external review, including audits and compliance reports.
• Participate in quality improvement initiatives and contribute to policy and procedure development.
• Maintain current knowledge of state and federal regulations, payer requirements, and industry trends in utilization review.
• Serve as a liaison between the hospital, patients, families, and third-party payers to resolve any utilization or care coordination issues.

Skills / Abilities:

• Strong analytical and problem-solving skills to assess clinical data and utilization trends.
• Excellent communication and interpersonal skills for working with diverse teams and stakeholders.
• Ability to handle confidential information and maintain compliance with privacy regulations.
• Proficient in electronic health record (EHR) systems and other healthcare software applications.
• Detail-oriented with the ability to manage multiple tasks and meet deadlines in a dynamic environment.

Education, Certificates, and License:
Education:

• Associate or Bachelor’s Degree in Nursing (ASN or BSN) required.

Certificates / License:

• Current Registered Nurse (RN) license in the state of Missouri or the ability to obtain.
• Certification in Utilization Review or Case Management (e.g., ACM, CCM) preferred but not required.

Experience:

• Minimum of 2 years of clinical nursing experience in a hospital or healthcare setting.
• Previous experience in utilization review, case management, or quality improvement preferred.

Physical Requirements:

• Mobility: Frequent standing, walking, or moving to various areas within the hospital.
• Dexterity: Fine motor skills to operate computer systems and review documentation.
• Posture: Ability to sit or stand for extended periods during data analysis and reporting.
• Lifting: Occasionally lift files or equipment weighing up to 10 lbs.

EEOC Statement:
Harrison County Community Hospital District provides equal employment opportunities to all employees and applicants and prohibits discrimination and harassment of any type, without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity, or any other characteristic protected by law.

This job description is not designed to cover all duties and responsibilities that may be required. Duties, responsibilities, and activities may change at any time with or without notice.