Top Utilization Review Coordinator Skills

Below we've compiled a list of the most important skills for an Utilization Review Coordinator. We ranked the top skills based on the percentage of Utilization Review Coordinator resumes they appeared on. For example, 8.0% of Utilization Review Coordinator resumes contained Insurance Companies as a skill. Let's find out what skills an Utilization Review Coordinator actually needs in order to be successful in the workplace.

The six most common skills found on Utilization Review Coordinator resumes in 2020. Read below to see the full list.

1. Insurance Companies

high Demand
Here's how Insurance Companies is used in Utilization Review Coordinator jobs:
  • Communicate with insurance companies to complete concurrent or step down reviews to request additional time for patients in detoxification or rehabilitation.
  • Relay therapeutic information to insurance companies in order to authorize coverage of treatment for inpatient and outpatient chemical dependency treatment.
  • Coordinated safe and appropriated discharge planning with patients, family members, providers and insurance companies decreasing unapproved hospital days.
  • Supervised thirteen employees to ensure daily reviews of medical information were communicated to the insurance companies per contractual agreement.
  • Provide written communication to management and third party interests such as insurance companies regarding patient cases.
  • Reviewed charts and communicated with various insurance companies regarding necessity of hospitalization and length of stay.
  • Coordinate patient care between physicians and insurance companies, verify insurance protocol for inpatient hospital stays
  • Obtained initial and continuing stay authorizations from insurance companies for clients in an inpatient facility.
  • Reviewed medical inpatient charts to obtain information to report to insurance companies for authorization.
  • Reported patient conditions to insurance companies/agencies and provided periodic updates for continuation of care.
  • Complete authorizations for acute adult unit for commercial insurance companies.
  • Documented unresolved issues with insurance companies regarding client coverage.
  • Obtained certifications from insurance companies.
  • Maintain contact with insurance companies for the intention of continued stay and discharge along with assistance in with referrals and aftercare.
  • Collaborated with Patient Accounts, Health Information Services and insurance companies to ensure appropriate documentation to support billing and coding.
  • Facilitate and analyze health insurance claims for insurance companies according to guideline criteria and plan language of their insurance policies.
  • Worked closely with the Case Managers, Doctors, and Insurance companies involved in the care of the patient.
  • Worked on past denials to the University to recuperate payment utilizing my past expertise with private insurance companies.
  • Worked with insurance companies for concurrent stay for client treatment and Assisted in Corporate Collections of Debt.
  • Developed strong working relationships with numerous Care Managers from different insurance companies to help improve patient care.

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2. Treatment Plans

high Demand
Here's how Treatment Plans is used in Utilization Review Coordinator jobs:
  • Collaborated with clinical staff to develop effective treatment plans, including measurable goals, evidence-based interventions, and appropriate aftercare planning.
  • Work closely with a multidisciplinary team to develop individualized treatment plans for patients
  • Provided concurrent and ongoing review of clinical treatment plans and documentation.
  • Assist in the identifying of individualized treatment plans for patients, as well as, in the coordination of discharge planning.
  • Performed Quality Assurance auditing of charts and collaborated with clinical staff to assist in development of overall master treatment plans.
  • Led daily multidisciplinary treatment teams on patient care and treatment plans / goals.
  • Communicate with Patients Primary care physicians upon admission when treatment plans changed.
  • Analyze all patient records and current treatment plans to determine medical necessity.
  • Develop Client treatment plans based on client history and clinical experience.
  • Perform audits to ensure documentation and treatment plans are sufficient.
  • Created individualized treatment plans and court reports.
  • Created and updated comprehensive treatment plans.
  • Authorized further treatment through case management and assessment of appeals by providers in emergency crisis management situations Assessed provider treatment plans
  • Justify treatment plans to Managed Care Organizations to obtain financial coverage.
  • Consult with therapist and physicians on treatment plans Interrupt clinical notes to present to insurance company.
  • Complete individualized treatment plans and all required documentation to meet JCAHO compliance.

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3. Medical Records

high Demand
Here's how Medical Records is used in Utilization Review Coordinator jobs:
  • Analyzed medical records to determine medical necessity, severity of illness and intensity of service using InterQual criteria.
  • Inputted and updated patient electronic medical records while ensuring quality assurance and the upkeep policies and procedures.
  • Organized medical records and confidential data and prepared accounts receivable and expected revenue reports for controllers.
  • Reviewed medical records for medical necessity and approved or denied authorizations based on the documentation provided.
  • Reviewed, analyzed reports and medical records to ensure accuracy for quality assurance and regulatory compliance.
  • Reviewed medical records to ensure compliance with established system and department indicators and regulatory standards.
  • Evaluate patients' laboratory and medical records, requesting assistance from other practitioners when necessary.
  • Communicated with sites on a regular basis regarding obtaining medical records and scheduling reviews.
  • Admissions-Reviewed medical records and clinical information from referring provider, families and assessments.
  • Review all inpatient medical records for medical necessity and appropriateness of admission setting.
  • Analyzed patient medical records submitted to the Utilization Department for outpatient Diagnostic Testing.
  • Audit outpatient medical records for compliance with regulatory and payer documentation requirements.
  • Managed medical records department and supervised medical records and census staff.
  • Reference appropriate medical records for QA/Risk Management/ and infection disease reviews
  • Followed agency and regulatory professional standards for maintaining medical records.
  • Maintained and retrieved active and archived patient medical records.
  • Reviewed medical records for documentation to justify in-patient hospitalization.
  • Audited inpatient medical records retrospectively for coding accuracy.
  • Perused medical records of medical malpractice cases.
  • Researched medical records by specialty and procedures.

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4. Ensure Compliance

high Demand
Here's how Ensure Compliance is used in Utilization Review Coordinator jobs:
  • Participated in implementing / maintaining operational processes to ensure compliance to company policies, legal requirements and regulatory mandates.
  • Co-developed policies and procedures for short stay observation to ensure compliance with Medicare and other regulatory agencies.
  • Conducted routine chart audits to ensure compliance with admission and continuing stay criteria and prepared summaries of audit findings.
  • Audit medical record data to ensure compliance and justify treatment or length of stay.
  • Review invoices to ensure compliance with vendor specific tariffs and policies.
  • Complete quality assurance audits to ensure compliance with agency standards.
  • Reviewed valuation reports to ensure compliance with client regulatory policies and specifications.

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5. Medical Necessity

high Demand
Here's how Medical Necessity is used in Utilization Review Coordinator jobs:
  • Coordinated non-participating referrals for medical necessity and appropriateness.
  • Participated in reviews to document medical necessity, continuity of care, compliance with payer contractual agreements and reimbursement.
  • Provide recommendations and education regarding incomplete documentation regarding coding guidelines, medical necessity requirements for level of care.
  • Process included reviewing for medical necessity, criteria, benefit interpretation, insurance eligibility, and data entry.
  • Review patient admission data and clinical documentation to ensure compliance relating to medical necessity and case documentation.
  • Perform clinical review of inpatient, outpatient and ancillary services to ensure medical necessity and appropriate setting.
  • Determined medical necessity for treatment/procedures under Medicare, Medical Assistance, Blue Cross and other insurance companies.
  • Performed telephonic reviews to establish appropriateness and medical necessity of admissions, stays, and discharge planning.
  • Participated in scheduled conferences with Interdisciplinary team for quality of care and medical necessity issues.
  • Determine medical necessity for inpatient hospitalizations and outpatient procedures via the telephone utilizing standard criteria.
  • Acquired knowledge of medical necessity requirements to avoid Hospital denials and increase overall revenue.
  • Chart reviews to determine medical necessity of requested services based on national standards.
  • Rendered medical necessity determinations for Medicare Part B and DMERC QIC Reconsideration Cases.
  • Reviewed prior authorization requests, using evidence-based criteria, to determine medical necessity.
  • Determined medical necessity and appropriateness for coverage and reimbursement of services provided.
  • Evaluated continuing medical necessity, and compliance with managed care utilization guidelines.
  • Review treatment requests from providers to determine medical necessity and appropriateness.
  • Reviewed cases not meeting medical necessity criteria with the Medical Director.
  • Acted as clinical resource person for determining medical necessity decisions.
  • Review admissions for medical necessity and appropriateness of admission.

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6. Patient Care

high Demand
Here's how Patient Care is used in Utilization Review Coordinator jobs:
  • Coordinated the intensive Case Management program monitoring patients with high utilization to ensure appropriate outpatient care was obtained by the patient.
  • Coordinate with discharge planning through active organization and monitoring of the patient care process to promote continuity of care cost effectiveness
  • Reviewed and maintained effective management of hospital resources in regard to patient care and the effectiveness of the discharge planning process.
  • Identify where the Agency could improve in providing better patient care, develop a plan and implement it with all staff.
  • Staff Nurse * Provided patient care and competently performed all clinical procedures associated with the particular specialty areas, i.e.
  • Reviewed patient care, treatment, admission, discharge, and documenting of patients requiring treatment at the hospital.
  • Identify problems related to the quality of patient care and refers such problems to the Quality Assurance Committee.
  • Assist in promotion of and maintenance of higher quality patient care through analysis, review, and evaluation.
  • Assured high quality patient care, appropriate, effective and efficient utilization of facilities and services.
  • Promote and maintain high quality patient care through appropriate utilization of facility's treatment services.
  • Supervised direct patient care, nursing management, assessments, and crisis management.
  • Provide direct patient care on an as-needed basis, as assigned by supervisor.
  • Reviewed patient care with insurance utilization managers on an as needed basis.
  • Identified potential problems and liabilities related to the quality of patient care.
  • Coordinate, monitor and manage patient care through continuum of services.
  • Set up standards for patient care in home.
  • Conducted concurrent and retrospective review for patient care.
  • Facilitated daily treatment team meetings with multi-disciplinary members to evaluate patient care.
  • Box 1408 Dublin, Georgia 31040 Phone: [ ] Responsibilities: Monitored patient care and the patient's hospital course.
  • Provide direct patient care Review ADRs

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7. Medical Services

high Demand
Here's how Medical Services is used in Utilization Review Coordinator jobs:
  • Verified prior medical and retro-claims for medical services, eligibility, medical groups, and hospital payment modifications.
  • Processed referrals for Workers Compensation claims from insurance adjusters for medical services.
  • Process Medicaid and Medicare authorizations for medical services.
  • Process authorizations for medical services.
  • Review and certify for medical services, including outpatient services, mental health, and therapies.
  • Reviewed and processed electronically faxed medical documents from Medical Providers to the Review Coordinators for medical services.

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8. Medicaid

high Demand
Here's how Medicaid is used in Utilization Review Coordinator jobs:
  • Participated in multiple outside agency surveys Medicaid Field Office, clinical reviews of internal processes and by other authorized government agencies.
  • Reviewed Medicare and Medicaid patient records for quality of care, utilization of resources and appropriate assignment of Diagnosis Related Groups
  • Served as a point of contact for emergency prior authorization for Colorado Medicaid Prescription Benefit Management Program.
  • Reviewed and coordinated inpatient Medicare, Medicaid and Workers Compensation charts for proper utilization of ancillary services.
  • Performed daily chart review for utilization appropriateness, working with commercial insurers and government agencies - Medicare/Medicaid.
  • Performed daily concurrent chart reviews to determine appropriateness for continued stay according to Medicare and Medicaid guidelines.
  • Consult with the Medical/Dental Director on Division of Medicaid policy and recommend necessary contract changes.
  • Worked closely with all Medicaid Hospice Providers to facilitate compliance with program and authorization requirements.
  • Use established medical criteria to certify necessity of inpatient status for Medicaid reimbursement.
  • Understand HIPPA, quality assurance and compliance issues governing Medicare/Medicaid/Commercial and Military insurance.
  • Returned to departmental office to make the calls required to insurance companies/Medicaid.
  • Relate all documentation and apply it to Division of Medicaid provided criteria.
  • Maintained working knowledge and use of Georgia Medicaid Management Information Systems.
  • Project work includes: Missouri Medicaid Retrospective Review / Certification Management.
  • Provide in-service training to agency staff on Medicaid Rehabilitation Option requirements.
  • Evaluated the appropriateness of care for Medicare and Medicaid hospitalizations.
  • Designed and implemented a program to ensure hospital Medicaid reimbursement.
  • Maintained ongoing communication with Care Management Organizations and Medicaid.
  • Coordinated hospital care for Medicare/Medicaid and third party patients.
  • Assumed responsibility for current knowledge of Joint Commission and Medicaid Standards as regards documentation for ECI admission, treatment and discharge.

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9. Concurrent Reviews

high Demand
Here's how Concurrent Reviews is used in Utilization Review Coordinator jobs:
  • Manage insurance process for 24-bed in-patient psychiatric facility including admission authorization, concurrent reviews, ECT authorization and Partial Hospitalization step-downs.
  • Conduct concurrent reviews for inpatient behavioral health hospital stays.
  • Complete concurrent reviews to justify the need for additional services at a specified level of care.
  • Perform clinical and concurrent reviews for treatment and other related services.
  • Scheduled, conducted and documented live concurrent reviews.
  • Provided initial and concurrent reviews with various insurance carriers Appealed insurance denials
  • Complete pre-certifications, initial and concurrent reviews within specific time frames.
  • Conducted behavioral health concurrent reviews, Pre-certifications authorizations.
  • Process preauthorizations, concurrent reviews, and aftercare requests
  • Call and initiate clinical and concurrent reviews for Level of care (detox,residential, PHP).
  • Performed precert and concurrent reviews on all active cases as assigned.
  • Conducted concurrent reviews with insurance providers (i.e.

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10. Clinical Staff

high Demand
Here's how Clinical Staff is used in Utilization Review Coordinator jobs:
  • Consulted with clinical staff concerning clinical documentation and the managed care process to educate staff and to ensure appropriate reimbursement.
  • Maintained effective working relationship with the centralized admissions department, creating a liaison between administrative staff and clinical staff.
  • Investigated denied authorizations and communicates with clinical staff when additional clinical information is needed.
  • Review all hospital Medicare B denials and wrote with clinical staff timely appeals for reimbursement.
  • Worked closely with clinical staff assisting in keeping the volume of activity organized and current.
  • Assisted clinical staff in the design of reviewing and reporting procedures.
  • Maintain communication with clinical staff and physicians for discharge planning.
  • Assist clinical staff with maintaining appropriate levels of care.
  • Participate in clinical staffing of patients.
  • Attended clinical staffing and staff/unit meetings.
  • Train and orient non-clinical staff.
  • Monitored documentation for compliance for Assisted with training clinical staff on documentation requirements for varied insurance organizations
  • Provided technical assistance and conducted trainings with clinical staff regarding service guidelines and medical necessity criteria.
  • Educate clinical staff regarding documentation of patient assement, treatment plan and progress notes.
  • Participate in weekly clinical staffings with various psychiatrist and social workers.
  • Presented clinical staff inservices and Maricopa Community College District Corporate

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11. Interqual

high Demand
Here's how Interqual is used in Utilization Review Coordinator jobs:
  • Monitored acute care provided to members utilizing McKesson InterQual criteria.
  • Reviewed member hospital stays for level of care and length of stay utilizing member benefits, medical criteria and InterQual criteria.
  • Assist physicians with appropriate LOC and placement order in ER and per phone per InterQual criteria.
  • Certified in InterQual ISD Criteria.
  • Conducted pre-certification of inpatient hospitalizations based on contract interpretations and InterQual criteria, using facility software programs.
  • Assisted and educated physicians regarding appropriate documentation and use of Interqual criteria.
  • Mastered Interqual performance for Utilization Management.
  • Coordinated review of patient records for RAC audits Managed and implemented InterQual criteria hospital wide with education for staff and physicians.
  • Manage a case load of hospitals by reviewing clinical information and using interqual guidelines, for commercial and Medicare patients.
  • Submitted authorization letters for care to hospitals, pending inpatient criteria was met, according to Interqual care guidelines.
  • Monitor the implementation and ongoing use of initial screening criteria (i.e., Interqual, ASAM).
  • Educate providers, facilities on IS/SI Interqual criteria and care standards in all care settings
  • Certified Instructor, teaching and training new and current employees in Interqual Criteria.
  • Assessed the appropriateness of patient's level of care with Interqual criteria.
  • Use and understand Interqual criteria.
  • Performed reviews and pre-admission certification using interqual criteria.
  • Reviewed cases for approval of psychiatric in-home and outpatient DMAS programs utilizing Interqual criteria.
  • Use of Interqual Criteria in the pre-authorization process.
  • Approved referrals and precerts that meet guidelines based on Interqual (TM) Medical Group policies developed by the Medical Director.

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12. Peer Review

high Demand
Here's how Peer Review is used in Utilization Review Coordinator jobs:
  • Collaborated with Utilization Committee MD to establish protocol and procedures for peer reviews, with ongoing professional development.
  • Peer reviewer for psychologists requesting approval for providing mental health treatment and psychological testing on an outpatient basis.
  • Schedule peer-to-peer reviews, commence discharge management pertaining to meets/not meets medical necessity criteria.
  • Trained and supervised volunteer co-peer reviewers assigned to assist with audit.
  • Coordinate and participate in peer-to-peer review as warranted.
  • Coordinated peer review services with psychiatrist
  • Tracked cases which have been recommended for denial through the peer review, independent medical review, and letter generation/mailing process.
  • Served as acting Director for Island Peer Review when Empire State Medical Scientific and Education Foundation lost the contract.
  • Supported and trained State CPA Society Peer Review Administrators on the AS/400 system, Web based programs and K-Net.
  • Coordinate and participate in physician review or peer-to-peer review for cases that fail to meet screening criteria.
  • Conduct peer to peer reviews if necessary with insurance company Doctors' as well as panel reviews.
  • Handle all appeals for denied services at either level of care, including peer to peer reviews.
  • Perform peer-to-peer reviews and appeal reviews, as needed, with insurance company doctor or clinical director.
  • Ensured the physicians had the materials, charts, and information for each peer review case.
  • Provide initial clinical, concurrent clinical, discharge planning, peer-to-peer reviews and coordination of appeals.
  • Review patient medical charts for Medicare insurance appeals and perform quality assurance on peer reviews.
  • Researched peer reviewed evidence-based supporting guidelines, criteria, and best practice standards of care.
  • Answer all emails and resolve any issues pertaining to transcription of medical peer reviews.
  • Coordinated peer review for Critical Care, Emergency Department, Operating Room and Anesthesiology.
  • Peer Review Committee member working closely with Chief of Staff and Hospital Director.

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13. Utilization Review

high Demand
Here's how Utilization Review is used in Utilization Review Coordinator jobs:
  • Prepared statistics and presented Medicare Regulations to various hospital department, including the Hospital Utilization Review Committee and Outpatient Advisory Committee.
  • Developed case management system to incorporate functions of utilization review, clinical social work, and referral source communications.
  • Performed utilization review of mental health services evaluating treatment plan appropriateness, effectiveness and quality of prescribed services.
  • Performed utilization review for renowned eating disorder facility to en- sure quality and procure funds to fuel operations.
  • Secured hospital admission and stay approval from insurance companies using computerized utilization review and DRG assurance applications.
  • Coordinated inpatient and outpatient Utilization Review process and coordination of appropriate documentation per CMS guidelines and standards.
  • Function as a liaison in collaboration with clinical departments and physicians for utilization review and educational purposes.
  • Provided support to individual departments in developing and implementing utilization review & documentation plan of actions.
  • Provided social work services for the emergency department, including utilization review problems and emergency transfers.
  • Performed utilization review of Medicare inpatient hospitalizations utilizing Severity of Illness and Intensity of Service criteria.
  • Conduct utilization review/medical management for durable medical equipment and perform preliminary research on requested topics.
  • Mail and fax Utilization Review determination letters to medical providers, injured workers and attorneys.
  • Traveled throughout the State as necessary to assist providers in management of utilization review program.
  • Gathered documentation in preparation for utilization review and appeal process when Medicare denied a claim.
  • Support clinical staff through completion of specific components of case management and utilization review process.
  • Worked as a Utilization Review Coordinator for approximately 55 patients on a Medical Telemetry Floor.
  • Collaborated with state and private insurance companies for prior approval authorizations and utilization review.
  • Provided clinically based utilization review of all patients receiving care in the hospital setting.
  • Oversee utilization review activities with other departments to ensure reimbursement for services provided.
  • Delegate online workers' compensation utilization review requests from providers submitting treatment requests.

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14. Mental Health Services

high Demand
Here's how Mental Health Services is used in Utilization Review Coordinator jobs:
  • Facilitated direct support for a team of 8 clinicians and members requesting mental health services.
  • Ensured staff compliance of HIPPA laws, State Medicaid compliance for mental health services.
  • Verify mental health services request and changes on levels of care.
  • Provide mental health services in nursing homes.
  • Worked collaboratively with executive level staff to ensure students received effective academic, behavioral and mental health services.
  • Provided accurate information regarding mental health services and MediCal coverage in a professional and sensitive manner.

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15. Review Coordinator

average Demand
Here's how Review Coordinator is used in Utilization Review Coordinator jobs:
  • Coordinate with Physician Review Coordinator Supervisor, Quality Audit Manager or Director for resolution of major complaints.
  • Assume role as temporary Physician Review Coordinator Supervisor in her absence.
  • Advised Lead Review Coordinator and other team members of the progress of projects assigned.
  • Served as a Review Coordinator.
  • Review Coordinator (2012 2013) Oversaw and assigned designated team of reviewers to medical facilities throughout New York City.

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16. Hospital Admissions

average Demand
Here's how Hospital Admissions is used in Utilization Review Coordinator jobs:
  • Determined medical necessity of Medicare hospital admissions, validated DRG assignments and appropriateness of discharge using InterQual criteria.
  • Establish and maintain efficient methods of ensuring the medical necessity and appropriateness of all hospital admissions.
  • Monitor the appropriateness of hospital admissions and extended hospitals stays.
  • Enter hospital admissions, monitoring and calling the hospitals to track discharges, and will forward these to the nurses.
  • Review for medical necessity outpatient procedures and inpatient hospital admissions via telephone and fax.
  • Acquired insurance authorizations for hospital admissions and procedures ordered by the attending physician.
  • Establish and maintain efficient methods of ensuring medical necessity and Longview, TX appropriateness of all hospital admissions with commercial insurance.

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17. Customer Service

average Demand
Here's how Customer Service is used in Utilization Review Coordinator jobs:
  • Communicate customer service/provider issues to up-line managers issue logs as appropriate.
  • Provide accurate information to callers based on customer service practices.
  • Provided Outstanding Customer Service in a call center environment.
  • Communicated customer service issues to supervisor when necessary.
  • Monitored, enhanced, managed, and trained the customer service team for all assigned project tasks and lines of business.
  • Performed other office duties as needed, such as telemarketing and customer service inquiries, billing patients and receiving payments.
  • Answer phones and give customer service or immediate advocacy to beneficiary, facility, and managed care plans.
  • Maintained a strong relationship between Health Provider sites and our Health Plan clients through excellent customer service.
  • Created authorization process for clinical treatment and customer service process for financial assessments and collections of fees.
  • Maintain cooperative working relationships with ICM (Case Management) and providers to ensure quality Customer service.
  • Use customer service and communication skills daily to coordinate between our customers and their financial institution.
  • Provided customer service to visitors who entered facility about 35% of the time.
  • Provide customer service from within and outside the department among many other tasks.
  • Addressed client concerns and defused irate and unsatisfied sites with quality customer service.
  • Provide customer service to individuals with claim, contract or participating provider inquires.
  • Provide utilization customer service support: auditing, reviewing and closing accounts.
  • Provide customer service to adjusters, claimants, attorneys and providers.
  • Set up medical appointments and provide customer service as required.
  • Provide customer service to insurance carrier and injured workers.
  • Provided customer service to patients ensuring quality of care.

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18. Durable Medical Equipment

average Demand
Here's how Durable Medical Equipment is used in Utilization Review Coordinator jobs:
  • Handled medical claims including, Inpatient, Outpatient, Durable Medical Equipment, and Outpatient Diagnostic Services.
  • Prepared authorization letters for durable medical equipment, DME, using Microsoft Word computer software.
  • Coordinated discharge planning of patients for skilled home health care and durable medical equipment.
  • Review procedures, durable medical equipment and home care services for medical necessity.
  • Initiated a joint venture with Home Health Services and Durable Medical Equipment Company.
  • Completed patient intake upon admission to hospice and ensure durable medical equipment, medication and transportation for patient destination was coordinated.

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19. Clinical Review

average Demand
Here's how Clinical Review is used in Utilization Review Coordinator jobs:
  • Provide first level clinical review for all inpatient and outpatient services requiring authorization for assigned client group regarding:
  • Obtain clinical review information from facilities across the nation regarding necessity for acute stay criteria.
  • Provided clinical reviews of medical record documentation to outside insurance review agencies.
  • Complete authorizations/certifications as permitted if clinical review not required.
  • Access and consult with peer clinical reviewers such as Team Leaders, Health plan.
  • Prepare and submit clinical reviews that were denied for service for secondary review.
  • Completed clinical reviews/ paper reviews according to client s insurance plan.
  • Perform clinical review and case management for private insurance patients.
  • Fax intake, distribution and logging of clinical reviews.
  • Perform hospital site visit for clinical review.
  • Delegate clinical reviewers to help ensure medically appropriate, quality, cost effectivecare throughout the medical management process.
  • Conduct Clinical Reviews and other communication and documentation as required by payor standard to obtain necessary certification.
  • Compile clinical data into an accurate clinical review and submit review to the payor within 24 hours of admission.
  • Worked in conjunction with Case Management to assure proper completion of clinical reviews before submission to each payor.
  • Pre-screened all referrals and provided initial clinical review for precert requests.

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20. Review Process

average Demand
Here's how Review Process is used in Utilization Review Coordinator jobs:
  • Document the insurance/managed care resources, review process and certification results concurrently in a concise manner-accessible to treatment team members.
  • Make recommendations to the manager regarding modifications of the review process to improve efficiency and productivity.
  • Entered and facilitated customer facing materials into Copy Review system to initiate review process.
  • Assisted President of the Utilization Committee in developing utilization committee plan with job descriptions and outline for review process.
  • Minimize losses due to timeliness of reviews by identifying accounts that may be problematic early in the review process.
  • Conduct assessments, reviews, and coordination of discharge planning activities and implementation of the review process.
  • Participated in Root Cause Analysis and Review Process with Selected Administrative Team.
  • Coordinated with Patient Registration and Clinical Admissions in the prospective review process.
  • Utilized MCG criteria set for the daily review process.
  • Increased customer understanding of the review process.
  • Established Filemaker Pro databases for new corporate Copy Review process and archive files.
  • Participate in system redesign of Peer Review Process.

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21. Appropriate Level

average Demand
Here's how Appropriate Level is used in Utilization Review Coordinator jobs:
  • Screened patients based on clinical appropriateness, acuity, and insurance eligibility to determine appropriate level of care.
  • Reviewed clinical records with attending physician and/or clinician to determine medical necessity for the appropriate level of care.
  • Collaborated with Medical Director and Physicians to ensure appropriate level of care for proper hospital reimbursement.
  • Determined patient acuity by evaluation of records and recommended appropriate level of care.
  • Carry a case load and ensure the clients are covered at the appropriate level of care.
  • Worked with high risk patients and helped find appropriate levels of care and follow up.
  • Coordinated with physicians, staff, and facilities regarding appropriate level of patient care.
  • Negotiated and advocated for patients length of stay and appropriate level of care.
  • Review of cases and documentation with Medical Director for appropriate level of care.
  • Attended daily meetings with staff to determine appropriate level of care for clients.
  • Certify clients for appropriate level of care based on ASAM guidelines.
  • Requested appropriate level of care for client upon completion of treatment.
  • Maintained an appropriate level of training in all areas of practice.
  • Determine appropriate levels of care by applying medical criteria.
  • Assessed clients for appropriate levels of care, ASAM criteria Coordinated with insurance providers for authorization of services.

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22. Data Entry

average Demand
Here's how Data Entry is used in Utilization Review Coordinator jobs:
  • Research and data entry using multiple systems and complete tasks as assigned.
  • Created new software database for work comp claims data entry.
  • Created data entry policies and processes to improve productivity.
  • Conducted data entry and updated in SRSA.
  • Review dental records and x-rays of service members, class them, treatment plan, data entry,
  • Case management Data Entry Answering phones DSM Codes
  • Oversee Nurses charting Discharge planner for patients Precertification for the patients Data entry and DSM5 coding for detox
  • Obtain Preauthorization for surgeries and radiological services Data entry- patient demographics and preauthorization documentation Answer phones and assist patients Other task assigned

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23. Medical Staff

average Demand
Here's how Medical Staff is used in Utilization Review Coordinator jobs:
  • Presented information to Medical staff on a regular basis regarding InterQual criteria and risk management based on concurrent auditing.
  • Communicated effectively with interdepartmental personnel, medical staff and outside agencies.
  • Perform clinical medical record review for medical staff using approved criteria.
  • Prepared documentation for medical review performed by medical staff and clinicians.
  • Coordinated quality assurance activities for medical staff committees
  • Functioned as liaison to the PRO (Peer Review Organization) and Medical staff for peer review and performance monitoring activities.
  • Educated medical staff with respect to current state regulations concerning hospital lengths of stay and proper medical chart documentations.
  • Served as department liaison to hospital administration and medical staff for policies and procedures.
  • Performed FPPE on all new medical staff or new procedures for Credentials.
  • Oversee the peer review process for the entire Medical Staff Services Department.
  • Analyzed data on a monthly basis and presented information to Medical Staff.
  • Worked closely with corporate legal resolving medical staff issues.
  • Assisted the medical staff in initiating discharge planning.
  • File maintenance as well as ensuring proper medical information is kept current to support claims examiner and medical staff needs.
  • Contract RN Medical Staffing Network, Boca Raton, Florida Worked in various Emergency rooms, primarily at Columbia Hospital.

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24. Substance Abuse

average Demand
Here's how Substance Abuse is used in Utilization Review Coordinator jobs:
  • Monitored commercial insurance compliance with Pennsylvania state mandated benefits for substance abuse treatment.
  • Conduct comprehensive intake assessments for incoming patients presenting with substance abuse/mental health issues.
  • Determined medical necessity for mental health and substance abuse treatment.
  • Analyzed dual diagnosis mental health and substance abuse caseloads to determine appropriateness of admission, treatment and length of stay.
  • Completed initial, concurrent, and discharge clinical reviews for inpatient mental health and substance abuse cases.
  • Work with third-party payers to ensure appropriate payment and utilization of Valley Hope substance abuse treatment services.
  • Managed a caseload; work closely with mental health, substance abuse, and geriatric populations.
  • Provide outreach for pregnant substance abusers in the North Philadelphia area.
  • Completed site reviews for substance abuse treatment providers.
  • Assisted with discharge planning Determined appropriate level of care for substance abuse as well as behavioral health reviews.
  • Complete pre-cert and concurrent reviews with insurance companies for clients seeking substance abuse treatment.

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25. Retrospective Reviews

average Demand
Here's how Retrospective Reviews is used in Utilization Review Coordinator jobs:
  • Provided telephonic concurrent and retrospective reviews to Insurance Companies that ensured approval of hospital stay.
  • Performed retrospective reviews, preventing considerable revenue loss by careful attention to details.
  • Performed all concurrent prospective and retrospective reviews.
  • Conducted initial, concurrent, and retrospective reviews of inpatient levels of care in a 240-bed behavioral health facility.
  • Coordinated visits from all Medical Plans and provided records for concurrent and retrospective reviews.
  • Process appeals for denied request as well as retrospective reviews.
  • Complete retrospective reviews and appeals.
  • Coordinated retrospective reviews and appeal process for denial of service by external payor.
  • Conducted telephonic pre-certifications, prospective, concurrent and retrospective reviews for the Mailhandlers Benefit PPO Plan.
  • conduct pre certification reviews, concurrent reviews, and retrospective reviews for insurance.

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26. Health Care

average Demand
Here's how Health Care is used in Utilization Review Coordinator jobs:
  • Work performance also included discharge planning during inpatient hospitalization and coordinating home health care services prior to hospital discharge.
  • Completed telephonic medical reviews with health care providers.
  • Respond to in-coming patient calls regarding authorizations for services; provide status and explaining request for their health care needs.
  • Coordinate patient care by holding team conferences with other physicians to design appropriate individual health care plans for patients.
  • Established discharge and outpatient service plans and collaborates with health care team and community agencies for continuity of care.
  • Confirm, verify & complete information for health care applications while adhering to privacy laws and policies.
  • Collaborate with physicians and other providers to facilitate provision of services throughout the health care continuum.
  • Maintained close communication with health care providers to ensure a safe transition to the home environment.
  • Recruited and provided training for new reviewers (physicians and other health care professionals).
  • Utilize various sources to verify patient insurance eligibility for DME and Home Health Care.
  • Improved record maintenance to support data analysis for trends and utilization of health care resources
  • Served as point person for vulnerable adult reporting and health care directive advisement.
  • Applied quality screens to ensure quality of care met health care standards.
  • Manage and implement clinical guidelines for appropriate health care treatment for patients.
  • Improved other health care providers awareness of length of stay criteria.
  • Coordinate Home Health care and DME for facility discharge patients.
  • Obtained prior authorizations for home health care and DME services.
  • Audit files and documents sent by health care providers.
  • Coordinated all aspects of home health care.
  • Processed referrals for various health care insurances.

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27. CPT

average Demand
Here's how CPT is used in Utilization Review Coordinator jobs:
  • Review of Medicare policy that outlines general and specific guidelines for the appropriate use of CPT codes for physician claims.
  • Documented CPT, HCPC and ICD9 codes in order for an approval for medical procedures for various providers
  • Assign ICD-9, CPT and HCPCS codes for medical clinic, obstetrics, laboratory, and orthopedics.
  • Prepare and submit claims using ICD-9, ICD-10, HCPCS, CPT codes and medical terminology.
  • Reviewed weekly assigned hospital claims using the correct ICD/CPT codes to ensure correct payment.
  • Ensured proper CPT and ICD 9 behavioral health codes were correctly administered to claims.
  • Open services using CPT codes and diagnosis codes for each service being provided.
  • Utilize knowledge of ICD-10 and CPT codes when documenting medical information in charts.
  • Use of knowledge of CPT codes to complete accurate fee audits for adjusters.
  • Developed strong knowledge of CPT codes and how to apply them.
  • Utilize knowledge of ICD-9-CM and CPT coding skills.
  • Referenced CPT codes, ICD-9 codes and medical terminology Forwarded clinical or medical necessity review to licensed health professionals as appropriate.
  • have knowledge on Medicare reviews, ICD-9 and CPT coding and Iuse a computer daily.
  • Entered referrals and precerts into software program accurately using ICD-9 and CPT coding.

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28. Party Payers

average Demand
Here's how Party Payers is used in Utilization Review Coordinator jobs:
  • Collected, assessed and monitored information pertaining to services provided and 3rd Party Payers.
  • Managed, prepared and submitted appeals to third party payers on clinical denials.
  • Work with third party payers regarding treatment progression of the client.
  • Crafted appeals for third-party payers, obtaining payment when denied.
  • Conduct reviews with third party payers for pre-certification and re-certification purposes.
  • Provided clinical reviews telephonically for third party payers.
  • Managed the transfer of information between third party payers and the medical and clinicalstaff members through the treatment team meeting process.
  • Reviewed patient charts on daily basis and conduct concurrent reviews with third party payers.

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29. Hipaa

average Demand
Here's how Hipaa is used in Utilization Review Coordinator jobs:
  • Encouraged members to attend regular appointments with their physicians and/or health care providers * Adhered to all confidentiality with HIPAA requirements.
  • Maintained patient confidentiality so that HIPAA compliance is observed at all times.
  • Apply Texas Medical Foundation (TMF), HIPAA criteria/regulations.
  • Prepared Patient Charts in accordance with HIPAA Compliance.
  • Required to Adhere to and participate in Company's mandatory HIPAA privacy program/practices, Business Ethics and Compliance programs/practices.
  • Apply Interqual, HIPAA criteria/regulations.
  • Executed accuracy and completeness with all tasks while maintaining medical recordintegrity within HIPAA guidelines Successfully recovered $300,000 in bad debts

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30. Milliman

low Demand
Here's how Milliman is used in Utilization Review Coordinator jobs:
  • Utilized Milliman and Robinson and InterQual approaches to determine appropriateness of standards.
  • Experience with InterQual and Milliman authorization criteria.
  • Reviewed Medicaid charts using Milliman guidelines.
  • Designed form to notify the attending provider and ancillary staff of the length of stay defined by Milliman criteria.
  • Uploaded inpatient cases and made determinations on lengths of stay based on necessity and Milliman and Robertson Criteria.
  • Frequent use of the Milliman & Roberts and Interqual for criteria for acute inpatient stays.
  • Utilized Morrisey program, InterQual and Milliman criteria to approve hospital stay.

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31. Chart Reviews

low Demand
Here's how Chart Reviews is used in Utilization Review Coordinator jobs:
  • Performed chart reviews to ensured proper documentation and monitored facility Census report for accuracy.
  • Contacted designated medical facilities to obtain location information for chart reviews.
  • Schedule appeals with Doctor or Nurse Practitioner when cases are denied, follow up with chart reviews if denial is upheld.
  • Schedule nurses to perform on-site medical chart reviews Supported nurses by providing work and direction while on site.
  • Verified locations and other information of various medical facilities in order to schedule chart reviews.
  • Contacted hospitals and doctors offices to coordinate chart reviews on behalf of health plans.
  • Contacted medical facilities to coordinate medical chart reviews on behalf of health plans.
  • Performed abstract chart reviews for such topics as medication errors and falls.
  • Scheduled multiple nurses to handle large volume chart reviews at various sites.
  • Increased efficiency of chart reviews by restructuring processes and procedures for review.
  • Schedule on-site medical chart reviews for site review consultants.
  • Consult work * Chart Reviews for Insurance Company
  • Coordinated and Scheduled onsite medical chart reviews with various medical offices and hospitals in an effective, efficient and professional manner.

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32. Hippa

low Demand
Here's how Hippa is used in Utilization Review Coordinator jobs:
  • Confirmed accuracy of client information and adhered to confidentiality standards based on HIPPA requirements.
  • Maintained productivity standards and adhered to confidentially per HIPPA regulations.
  • Maintained HIPPA privacy and confidentiality regulations.
  • Advise employees and sites of HIPPA regulations, and ensure that these procedures are being properly implemented.
  • Adhere to HIPPA compliance and company policies.
  • Adhere to HIPPA compliance and CIGNA guidelines.
  • Adhered to all confidentiality with HIPPA requirements.
  • Trained staff on the HIPPA standards.
  • Implement and abide by the rules and regulations of the HIPPA act and Inovalon Operating Policies and Procedures.

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33. Social Workers

low Demand
Here's how Social Workers is used in Utilization Review Coordinator jobs:
  • Collaborated closely with the Doctors, Case Managers, Social Workers in getting the Patients discharged to home or other facilities.
  • Communicate daily with physicians, bedside nurses, social workers, clinical affiliates and patients.
  • Track and provide daily updates to counselors and Social Workers on patient status.
  • Coordinate information with nursing, physicians, social workers and discharge planners.
  • Appraised Social Workers of discharge needs (i.e.
  • Collaborated extensively with social workers, physicians and other specialists to facilitate care processes and ensure comprehensive accuracy among all documentation.

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34. DRG

low Demand
Here's how DRG is used in Utilization Review Coordinator jobs:
  • Review charts for assigned patients, gather pertinent clinical information required to obtain commercial insurance approvals and assign DRG's.
  • Assisted the business office and physician offices with Insurance claims, DRG validation and APC coordination.
  • Corrected DRG assignments, as well as assign missed Secondary Diagnosis and CPT procedure Codes.
  • Developed monthly hospital wide news letter for staff education on DRG issues.
  • Maximized DRG's and confirmed quality care.
  • Worked with ICD 9 codes after the reviews to get a working DRG per case.
  • Assigned DRG payments for Medicare/ Medicaid and third party payors.

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35. CMS

low Demand
Here's how CMS is used in Utilization Review Coordinator jobs:
  • Interpreted CMS Regulations and incorporate requirements into operational policies and procedures.
  • Receive and reply up to 300 telephone calls/e-mail requests for automation information and CMS policy's interpretation on a monthly basis.
  • Analyzed and investigate pertinent data to solve issues outside the guidelines of Centers for Medicare Medicaid Services (CMS) Regulations.
  • Reviewed prior authorization requests accurately and according to CMS guidelines, AFMC, state, and federal policies and procedures.
  • Verify the validation of notices given to beneficiary and make sure they comply with CMS guidelines.
  • Maintained current knowledge of regulatory requirements and changes associated with CMS, The Joint Commission.
  • Refined policies and procedures for the Care Management Department in compliance with CMS standards.
  • Chart reviews on cases identified for review by HCFA(CMS).
  • Assisted in development of Observation Process as mandated by CMS;.

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36. Jcaho

low Demand
Here's how Jcaho is used in Utilization Review Coordinator jobs:
  • Demonstrate working knowledge of JCAHO standards, DSM IV diagnostic criteria and current Manage Care Organizations' level of care.
  • Organized and coordinated all preparations for the initial JCAHO certification of this facility's outpatient programs.
  • Researched and compiled data for OSHA, HCFA, JCAHO and other hospital quality control programs.
  • Developed and implemented the Pain Management program that resulted in a successful JCAHO survey.
  • Conducted special studies at the request of hospital administration and per JCAHO guidelines.
  • Worked with senior management personnel to prepare for JCAHO certification.

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37. HMO

low Demand
Here's how HMO is used in Utilization Review Coordinator jobs:
  • Identified quality concerns/appropriateness of inpatient medical necessity for HMO/POS members length of stay and facilitated discharge planning when appropriate.
  • Conducted on-site concurrent utilization and quality reviews of hospitalized HMO members.
  • Coordinated the Medicare appeals process within the QIO with patients, HMO's, nurse and physician reviewers and case managers.
  • Work with all commercial payers managed care as well as government Medicaid, Medicare and all Medicaid and Medicare HMO plans.
  • Provided supervisory and charge nurse duties for staff nurses and nursing assistants in a high risk HMO pediatric clinic.
  • Review and management of all HMO member Psychiatric cases, Third party Consultation, Documentation and Follow up.
  • Instructed hospital staff of member's HMO plan benefits and authorized length of stay for their hospitalization.
  • Experienced in working with HMO network providers (hospitals, physician offices and ancillary providers).
  • Reviewed HMO patients in contracted long term care facilities for skilled level of care.
  • Executed system testing and development of administrative policies for the new HMO product.
  • Conducted HMO required audits to monitor compliance with HMO mandated QI projects.
  • Implemented and maintained UR/QA filing system and conducted HMO Coalition quality audits.
  • Consulted with hospital discharge planners for post hospital care of HMO members.
  • Experience includes HMO, PPO and POS plans.
  • Tracked and reported statistical information regarding patients of Integris HMO group.
  • Developed processes for pre-certification for PPO and HMO groups.
  • Formulated HMO Prescreening (Precert Plus) program for membership of 68,000 which entailed nurse, patient and physician interview processes.

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38. Care Companies

low Demand
Here's how Care Companies is used in Utilization Review Coordinator jobs:
  • Articulate relevant clinical information to managed care companies based on level of care necessity.
  • Contacted managed care companies/insurance companies daily for concurrent reviews.
  • Coordinated the appeal process in an effort to overturn denied services by managed care companies, Medicaid, and Medicare.
  • Facilitated certification of patient's treatment by acting as liaison between the hospital and the managed care companies.
  • Completed reviews with managed care companies to negotiate appropriate length of stay and ensuring reimbursement.
  • Fostered excellent relationships with care managers at all major managed care companies.
  • Work closely with managed care companies for pre authorizations for care as outpatient or skilled nursing and rehab.
  • Initiated and telephonic or electronic reviews with managed care companies for all programs Monitored utlization and staff completion of Authorization Record Forms

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39. Phone Calls

low Demand
Here's how Phone Calls is used in Utilization Review Coordinator jobs:
  • Completed more than 30 telephone calls daily from mental health providers and clients, exceeding individual goal and enhancing service results.
  • Initiated telephone calls to members, and received telephone calls from members to perform telephonic health risk assessments.
  • Answered incoming emails and phone calls related to order assignments in time to maintain efficient appraisal order process.
  • Receive incoming and make outgoing phone calls to providers and physicians.
  • Answer emails and phone calls from Appraiser and Branch Staff.
  • Receive and place phone calls from/to sites regarding audits.
  • Answer telephone calls during normal business hours.
  • Manage multiple phone calls at once.
  • Managed a multi line telephone by answering and transferring telephone calls to appropriate staff members.
  • Answered incoming phone calls and assisted claimants, adjustors and providers as appropriate.
  • Answered all phone calls regarding referrals and precerts.

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40. Inpatient Admissions

low Demand
Here's how Inpatient Admissions is used in Utilization Review Coordinator jobs:
  • Review of all inpatient admissions assuring appropriate level of care and justification of hospital admission for payment.
  • Obtained commercial insurance coverage for inpatient admissions at a 99-bed psychiatric hospital and residential facility.
  • Perform utilization review of inpatient admissions, outpatient surgeries, and ancillary services.
  • Analyze insurance standards to determine criteria for inpatient admissions.
  • Obtain Pre-Certification approvals for Inpatient Admissions.
  • Used nationally accepted criteria (InterQual) to monitor inpatient admissions for appropriateness of care and length of stay.
  • Do initial, concurrent, and retro reviews via clinical chart assessments for medical necessity for inpatient admissions.
  • Reviewed all inpatient admissions and outpatient procedures to assure appropriate level of care.
  • Assessed acute care hospitalizations for appropriateness/necessity of inpatient admissions or care telephonically and on site.
  • Verify pre-certification for all inpatient admissions and surgeries.
  • Conduct reviews on all inpatient admissions using Milliman Care Guidelines.

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41. Outpatient Clinic

low Demand
Here's how Outpatient Clinic is used in Utilization Review Coordinator jobs:
  • Reviewed benefit services for members in hospitals, outpatient clinics, rehabilitation facilities, and skilled nursing facilities.
  • Front and back office management of a chemical dependency outpatient clinic, where she managed 250-300 patients on a daily basis.

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42. Medical Review

low Demand
Here's how Medical Review is used in Utilization Review Coordinator jobs:
  • Communicated medical review to managed care organization for reimbursement.
  • Performed medical reviews of concurrent rehabilitation patient services.
  • Scheduled and coordinated Independent Medical reviews and examinations.
  • Analyzed documented information to develop plan of action for scheduling sites, and prepared reports to perform medical reviews.
  • Assist providers with medical review of a request claim for ER PLP triage service(s).
  • Maintained medical reviews and denial letters for appeals and reconsiderations.

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43. Ensure Accuracy

low Demand
Here's how Ensure Accuracy is used in Utilization Review Coordinator jobs:
  • Performed quality control over-read reviews of previously completed record reviews to ensure accuracy and completeness.
  • Maintained databases and spreadsheets to ensure accuracy in records.
  • Reviewed work done by others in the department to ensure accuracy of company policy and to provide recommendations for revision.
  • Prepared and reviewed operational reports and schedules to ensure accuracy and efficiency.

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44. RN

low Demand
Here's how RN is used in Utilization Review Coordinator jobs:
  • Peer Review report assignment and editing to ensure reports met company professional standards and scientific/medical journal article submission format and standards.
  • Identified patterns of fraud, abuse, and gross overuse of medications using retrospective analysis and implemented corrective actions when needed
  • Serve as liaison between internal and external key stakeholders in ensuring timely and appropriate utilization of services for covered membership.
  • Performed investigations for allegations of quality of care concerns relative to the care provided to and afforded under Medicare benefits.
  • Report utilization trends, clinical issues and operational concerns regarding LOC within Behavioral Service Delivery System to Clinical Manager.
  • Identify potentially unnecessary services and care delivery settings, and recommend alternatives if appropriate by analyzing clinical protocols.
  • Developed recommendations for alternative care and resources in order to maximize member benefits and provide cost efficient care.
  • Processed pharmaceutical claims using online database and Internet intranet to provide essential information to providers or participants.
  • Communicated and coordinated with Physician Reviewers regarding referral of cases with utilization and/or quality of care concerns.
  • Advised provider community on the administrative aspects concerning documentation submitted for clinical review and medical necessity.
  • Reviewed and coordinated clinical utilization payer expectations for each patient admission where external payment options existed.
  • Applied International Classifications of Disease and Current Procedural Terminology with appropriate Medicare Part B claim review.
  • Assisted participants with identification of alternative funding sources when benefits exhausted or there were benefit exclusions.
  • Customized internal procedures to maximize efficiency of service approval processes and streamline cost allocation per caseload.
  • Address patient concerns regarding financial obligations and insurance coverage, providing patient education and financial options.
  • Provide all external review organizations the information necessary to complete reviews and effect maximum reimbursement.
  • Prepare charts, graphs, oral and written communications to satisfy internal/external reporting requirements.
  • Performed medical record reviews for Risk Management and Hospital Attorneys for litigation issues.
  • Analyzed patient records to determine compliance with government and insurance reimbursement policies.
  • Governed approval for covered services, overseeing internal and external utilization management.

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45. Additional Information

low Demand
Here's how Additional Information is used in Utilization Review Coordinator jobs:
  • Reviewed physician review requests to ensure that all required information is available and contacts customer if additional information is required.
  • Determine what additional information or documentation is needed to satisfy admission criteria and take action to educate providers.
  • Correspond with physician's offices to verify information and request additional information.
  • Follow up with the requesting physician for missing or additional information.
  • Contacted physician offices to obtain additional information on referrals and precertifications.
  • Followed up with nursing facilities to obtain additional information when necessary.

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46. QA

low Demand
Here's how QA is used in Utilization Review Coordinator jobs:
  • Audited clinical documentation and monitored phone conversations to ensure that NCQA standards were being maintained.
  • Participated in development strategies for the MICQAR project with the Long-Term Care Division of the Michigan Department of Community Health.
  • Handled insurance appeals and denials through Medicare's AQAF process as well as BCBS and commercial companies.
  • Proof read and QA'd provider medical reports for errors in review.
  • Assured documentation for acute care and monitored QA issues.
  • Utilize the Qnet and FMQAI for reports, updates, etc.

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47. Hedis

low Demand
Here's how Hedis is used in Utilization Review Coordinator jobs:
  • Chart over-reads for Hedis Measures.
  • Reviewed and abstracted specific clinical data from electronic charts and integrated required HEDIS data into proprietary software.
  • Collaborated with contractors for provider government based programs for review and analysis of HEDIS performance measures.
  • Performed provider site visits to obtain required HEDIS documentation.
  • Conducted extraction of HEDIS information according to specific guidelines.
  • Performed medical record data review/abstraction for HEDIS measures

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48. Computer System

low Demand
Here's how Computer System is used in Utilization Review Coordinator jobs:
  • Placed clinical information into computer system to allow review by physicians.
  • Track information on a daily basis by entering current certification information into MIDAS and AS400 and Tier computer systems.
  • Utilize computer skills to find necessary information on different drives on the computer system used by the agency.
  • Document all reviews and outcomes in computer system.
  • Enter patient intake demographics and clinical information in Billing and Clinical computer systems.
  • Ensured new customer demographic is accurately entered in the computer system.

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49. Special Projects

low Demand
Here's how Special Projects is used in Utilization Review Coordinator jobs:
  • Prepare weekly/monthly audit reports for director and executive management and special projects as needed.
  • Analyzed data and prepared other reports for special projects on request of department manager.
  • Participated in committees and special projects.
  • Worked closely with Chief Operating Officer and Chief Executive Officer on special projects.Six-month preparation for state audit completed.
  • Research and compile data for special projects and reports.
  • Performed special projects as assigned by management.

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20 Most Common Skill for an Utilization Review Coordinator

Insurance Companies10.7%
Treatment Plans9.1%
Medical Records8.9%
Ensure Compliance7%
Medical Necessity6.6%
Patient Care6.5%
Medical Services6.2%
Medicaid5.9%

Typical Skill-Sets Required For An Utilization Review Coordinator

RankSkillPercentage of ResumesPercentage
1
1
Insurance Companies
Insurance Companies
8%
8%
2
2
Treatment Plans
Treatment Plans
6.9%
6.9%
3
3
Medical Records
Medical Records
6.7%
6.7%
4
4
Ensure Compliance
Ensure Compliance
5.2%
5.2%
5
5
Medical Necessity
Medical Necessity
4.9%
4.9%
6
6
Patient Care
Patient Care
4.9%
4.9%
7
7
Medical Services
Medical Services
4.7%
4.7%
8
8
Medicaid
Medicaid
4.5%
4.5%
9
9
Concurrent Reviews
Concurrent Reviews
4.2%
4.2%
10
10
Clinical Staff
Clinical Staff
3.7%
3.7%
11
11
Interqual
Interqual
3%
3%
12
12
Peer Review
Peer Review
2.4%
2.4%
13
13
Utilization Review
Utilization Review
2.4%
2.4%
14
14
Mental Health Services
Mental Health Services
2.3%
2.3%
15
15
Review Coordinator
Review Coordinator
2.2%
2.2%
16
16
Hospital Admissions
Hospital Admissions
2.1%
2.1%
17
17
Customer Service
Customer Service
2.1%
2.1%
18
18
Durable Medical Equipment
Durable Medical Equipment
1.7%
1.7%
19
19
Clinical Review
Clinical Review
1.6%
1.6%
20
20
Review Process
Review Process
1.5%
1.5%
21
21
Appropriate Level
Appropriate Level
1.5%
1.5%
22
22
Data Entry
Data Entry
1.4%
1.4%
23
23
Medical Staff
Medical Staff
1.4%
1.4%
24
24
Substance Abuse
Substance Abuse
1.3%
1.3%
25
25
Retrospective Reviews
Retrospective Reviews
1.2%
1.2%
26
26
Health Care
Health Care
1.2%
1.2%
27
27
CPT
CPT
1.1%
1.1%
28
28
Party Payers
Party Payers
1%
1%
29
29
Hipaa
Hipaa
1%
1%
30
30
Milliman
Milliman
1%
1%
31
31
Chart Reviews
Chart Reviews
0.9%
0.9%
32
32
Hippa
Hippa
0.9%
0.9%
33
33
Social Workers
Social Workers
0.9%
0.9%
34
34
DRG
DRG
0.9%
0.9%
35
35
CMS
CMS
0.8%
0.8%
36
36
Jcaho
Jcaho
0.8%
0.8%
37
37
HMO
HMO
0.8%
0.8%
38
38
Care Companies
Care Companies
0.7%
0.7%
39
39
Phone Calls
Phone Calls
0.7%
0.7%
40
40
Inpatient Admissions
Inpatient Admissions
0.6%
0.6%
41
41
Outpatient Clinic
Outpatient Clinic
0.6%
0.6%
42
42
Medical Review
Medical Review
0.6%
0.6%
43
43
Ensure Accuracy
Ensure Accuracy
0.6%
0.6%
44
44
RN
RN
0.6%
0.6%
45
45
Additional Information
Additional Information
0.5%
0.5%
46
46
QA
QA
0.5%
0.5%
47
47
Hedis
Hedis
0.5%
0.5%
48
48
Computer System
Computer System
0.5%
0.5%
49
49
Special Projects
Special Projects
0.5%
0.5%

5,184 Utilization Review Coordinator Jobs

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