STATE OF NEW HAMPSHIRE
HUMAN RESOURCES
CLASSIFICATION: UTILIZATION REVIEW COORDINATOR
Class Code: 9660-20
Date Established: 06-23-76
Occupational Code: 7-4-1
Date of Last Revision: 12-28-01
BASIC PURPOSE: Performs responsible administrative
work in the determination of method and operations for the review of medical
records of persons admitted for psychological or medical care.
CHARACTERISTIC DUTIES AND RESPONSIBILITIES:
·
Conducts admission
review on all individuals admitted to New Hampshire Hospital to determine the
appropriateness of each admission.
Certifies the admission using established criteria and issues notices of
non-coverage as indicated.
·
Consults with
physicians or members of the treatment team when conducting concurrent review
of all inpatients, and certifies the continued hospital stay or issues notices
of non-coverage as indicated.
·
Meets with
patients/legal representatives to discuss notices of non-coverage, and the
potential financial liability as a result of these decisions.
·
Organizes clinical
information and conducts telephone utilization review with third party
payors/managed care companies for the purpose of determining each patients’
level of care, certifying admission and continued hospital stay and seeking
reimbursement for these hospitalizations, and communicates the results of these
decision.
·
Assists physicians in
appealing notices of non-coverage issued by managed care companies and tracking
the results of that process.
·
Consults with the
Office of Reimbursement and other Hospital departments regarding financial
issues that may affect hospitalized patients, including but not limited to, the
impact of notices of non-coverage on an individual’s financial liability.
·
Maintains and collates
statistical data pertaining to the utilization review of federally and
non-federally funded patients which is used in medical staff and Hospital-wide
reporting.
·
Conducts concurrent
and retrospective review of the medical record documentation and the clinical
care provided to all patients; monitors Hospital and medical staff performance
using pre-established criteria and reports the findings as directed.
·
Maintains current
knowledge of state and federal regulations as they pertain to utilization and peer
review and the impact these regulations have on the review process. Assists in coordinating review
activities conducted by external review and regulatory agencies.
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DISTINGUISHING FACTORS:
Skill: Requires skill in developing formats
and procedures for special applications OR in investigating and reviewing the
use of equipment and data for a specialized function.
Knowledge: Requires logical or scientific
understanding to analyze problems of a specialized or professional nature in a
particular field.
Impact: Requires responsibility for
contributing to immediate, ongoing agency objectives by facilitating the direct
provision of services to the public or other state agencies. Errors at this level result in
inaccurate reports or invalid test results and require a significant investment
of time and resources to detect.
Supervision: Requires partial supervision of other
employees doing work which is related or similar to the supervisor, including
assigning job duties, providing training, giving instructions and checking
work.
Working Conditions: Requires performing regular job
functions in a controlled environment with minimal exposure to disagreeable job
elements and little risk of hazard to physical or mental health.
Physical Demands: Requires light work, including
continuous walking or operating simple equipment for extended periods of time
as well as occasional strenuous activities such as reaching or bending.
Communication: Requires summarizing data, preparing
reports, and making recommendations based on findings which contribute to
solving problems and achieving work objectives. This level also requires presenting information for use by
administrative-level managers in making decisions.
Complexity: Requires coordinating a combination of
diverse job functions in order to integrate professional and technical agency
goals. This level also requires
considerable judgment to implement a sequence of operations or actions.
Independent Action: Requires objective assessment in
analyzing and developing new work methods and procedures subject to periodic
review and in making decisions according to established technical, professional
or administrative standards.
MINIMUM QUALIFICATIONS:
Education: Bachelor’s degree from a recognized
college or university with a major study in a healthcare related field. Each additional year of approved formal
education may be substituted for one year of required work experience.
Experience: Three years of clinical experience in a
healthcare setting. Each
additional year of approved work experience may be substituted for one year of
required formal education.
License/Certification: None required.
RECOMMENDED WORK TRAITS: Knowledge of medicine and diagnostic
procedures. Working knowledge of
scientific, psychological and therapeutic procedures as provided in hospitals
and other medical or psychiatric medical-care facilities. Ability to maintain accurate records
and medical care histories.
Ability to deal effectively with personnel engaged in treatment and
training programs. Considerable
tact required in dealing with superiors, agency heads as well as residents,
parents and friends. Ability to
work without supervision. Must be
willing to maintain appearance appropriate to assigned duties and
responsibilities as determined by the appointing authority.
DISCLAIMER STATEMENT: This class specification is descriptive
of general duties and is not intended to list every specific function of this
class title.
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Last Updated 10/21/04
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