The Utilization Review Coordinator functions as the primary liaison between the hospital, payor contacts, and all other related parties to ensure appropriate level of care through comprehensive concurrent review for medical necessity of outpatients in a bed (SDC, cath lab, IR, etc.), outpatient observation and inpatient stays and the utilization of ancillary services. The Utilization Review Coordinator is responsible for oversight of UR and ED Case Managers and will assist with the programmatic management of the revenue integrity cycle inclusive of the medical necessity/level of care appeals and denials, the length of stay across the continuum; monitoring and analyzing utilization and quality trends and make recommendations to management on improvement opportunities. DUTIES AND RESPONSIBILITIES: + Ensures efficient and effective delivery of patient care services through appropriate utilization of resources. + Responsible for completing pre-admission reviews for scheduled surgeries to ensure appropriate documentation is in place to support medical necessity & level of care ordered. + Utilizing InterQual® Level of Care Criteria, ensures appropriate service assignment (inpatient vs observation) and collaborates with attending MD to reduce possibility of reimbursement medical necessity/level of care denials. + Prepare and submit concurrent appeals to third party payors, effectively coordinating collection of all pertinent data to support the hospital and patient’s position. + Responsible for monthly UR quality assurance monitoring efforts, staff performance follow-up, and escalation of continued quality concerns to department leadership. + Maintain and update quality assurance monitoring tracking logs of review and other appropriate records for the utilization review department. + Communicate pertinent third-party payors issue to physicians and treatment team. + Stay abreast of applicable UR trends and make recommendations to management on improvement strategies. + Collaborates with clinical staff to provide education, feedback, and assistance regarding documentation of medical necessity, insurance review criteria, and coordinates continuity of care with facility revenue staff as needed. + Collaborates with the facility revenue staff for documentation and provides the necessary information to the staff at the facility. + Works with the Clinical Care Coordinator and Complex Care Manager to ensure patients are discharged appropriately to alternative sites in a timely manner to prevent delay days and denials. + Perform operational duties as needed and assigned such as payroll, cover utilization review nurses if there is a significant staffing challenge. + Other duties as assigned. EDUCATION AND RELATED EXPERIENCE: Required: + Graduate of an accredited professional nursing school + Current Massachusetts Nursing license + Associates required, bachelor’s preferred or equivalent years of experience + 5 years case management experience in an acute care setting with discharge planning, continuing care, care management, and utilization review. + Five years clinical nursing experience required + Case Management Essentials – Certificate Program, must be completed within 6months of being the role. + HCPro Medicare Boot Camp: Utilization Review Online within 6 months of being in the role. + HCPro CDI and Documentation Boot Camp within 12 months of being in role. + Demonstrated verbal, written skills + Interpersonal skills required + Critical thinking and knowledge of regulatory standards and reimbursement requirements + Computer skills required Preferred: + Master’s degree. Lawrence General Hospital is a private, non-profit community hospital providing the Merrimack Valley & southern New Hampshire regions with patient-centered, compassionate, and quality health care for the whole family. For over 140 years, the dedicated doctors, nurses, and staff of Lawrence General have been committed to improving the health of the people and communities we serve. LGH offers competitive pay, a robust benefit package, generous paid time off and free parking. We are an Equal Opportunity Employer committed to hiring a diverse workforce.