Hospital - Utilization Review Care Coordinator (RN)

The Utilization Review (UR) Care Coordinator in the Care Management Department will be responsible for ensuring the appropriate use of healthcare resources while maintaining high standards of patient care.  The individual in this position will review patient cases, monitor treatment plans, and collaborate with healthcare providers to optimize care delivery and resource utilization.

• Conduct utilization reviews to ensure medical necessity, appropriateness, and efficiency of healthcare services.
• Evaluate patient records, treatment plans, and clinical documentation to verify that services meet established guidelines and standards.
• Collaborate with physicians, nurses, case managers, and other healthcare providers to discuss patient care and identify opportunities for improvement.
• Facilitate the authorization process for hospital admissions, treatments, and procedures with insurance companies and payers
• Monitor patient progress and discharge plans to ensure timely and appropriate transitions of care.
• Educate patients, families, and healthcare providers about utilization review processes and requirements.
• Maintain accurate and detailed documentation of reviews, findings, and actions taken.
• Participate in interdisciplinary team meetings to discuss patient care and utilization management.
• Stay current with industry regulations, standards, and best practices in utilization review and care management.

• Comprehensive understanding of utilization review processes, guidelines, and regulations.
• Knowledge of medical terminology, disease processes, and treatment protocols.
• Familiarity with healthcare delivery systems and insurance requirements.
• Understanding of regulatory requirements, including Medicare and Medicaid guidelines.
• Strong analytical and critical thinking skills.
• Proficient in reviewing and interpreting medical records and clinical documentation.
• Ability to work collaboratively with a multidisciplinary healthcare team.
• Capacity to handle multiple priorities and manage complex cases.
• Ability to advocate for patients and ensure the appropriate use of healthcare resources.
• Flexibility and adaptability to meet the diverse needs of patients and the healthcare system.

Education

• Bachelor's in Nursing

Certification/Licensure:

• Registered Nurse (RN)