STATE OF NEW HAMPSHIRE
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.
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.
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.
Last Updated 10/21/04