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Medical Review Coord. - Social Service - Full Time - Days

Company: Mission Regional Medical center
Location: Harlingen
Posted on: June 6, 2021

Job Description:


Coordinates and completes the clinical reviews for all patient medical records while working closely with CMO (Chief Medical Officer). Actively participates in the Case management and UR meetings. Serves as on-going educator to all departments. Responsible for reviewing patient charts in order to assess whether the clinical criteria for admission and continuation of treatment is being met; gathering data and responding to request for records from payers/fiscal intermediary etc.; gathering clinical and fiscal information and communicating status of both open and closed accounts for multiple levels of Utilization Review and Case Management reporting. Able to work independently and use sound judgment. Knowledge of Federal, State, and intermediary guidelines related to inpatient, acute care hospitalization, as well as lower levels of care for the continuity of treatment. Coordinates discharge referrals as requested by clinical staff, fiscal intermediary, patients, and families. Performs other duties as assigned.


  1. Requisite skills to float to a variety of clinical areas, assess clinical criteria of all new patients for admission and performs utilization review and preauthorization as well as concurrent clinical authorization and reviews.

  2. Reviews admissions within 24 hours excluding holidays and weekends and prepares for daily Case Management meetings.

  3. Reviews inpatient medical records for identified payor populations (i.e., Medicare, etc.) as directed on admission and throughout hospitalization. Analyzes clinical status of patient, current treatment plan and past medical history and ensure that utilization reviews are performed as required.

  4. Reviews payor information and perform utilization reviews as necessary for admission authorization and approval for continuation of treatment.

  5. Completes and submits authorization requests in a timely manner as requested. Enters all authorizations and status of accounts into the hospital-wide tracking system.

  6. Maintains active file of denials and reports status to the Director as requested.

  7. Assists in preparing accounts for the appeal process by tracking deadlines, reviewing clinical information, writing appeal requests generating and submitting new TAR's.

  8. Facilitates the appropriate clinical documentation to ensure that the intensity of services and level of acuity of the patient is accurately reflected in the medical record. Ensures abnormal findings are addressed, and the patient's past medical history of conditions is appropriately documented.

  9. Works with health information management staff, coding staff, physicians, financial services, onsite and remote utilization review teams with regards to admission criteria, medical necessity, payment denials, and documentation issues. Instructs staff on proper documentation in the medical record.

  10. Performs other duties as assigned or required.


Required qualifications:

  1. Master of Public Health (MPH) or post-graduation in a related health care field is required.

  2. Medical Graduate, Dental Graduate required.

  3. Knowledge of Clinical Pathophysiology and Pharmacology required.

Preferred qualifications:

  1. ECFMG Certification And/or Bachelor's or higher from a US-based accredited institution in a Health and Human Services field is highly preferred.

  2. Utilization Review/Case Management experience is highly preferred.

  3. 1+ year of clinical experience in acute care setting preferred.

  4. Excellent written and verbal communication skills. Excellent critical thinking skills.

  5. Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff, coding staff and hospital management staff.

  6. Ability to work independently in a time-oriented environment.

  7. Computer data entry with 10-key preferred, with accurate typing speed of 35 wpm preferred.

We are an Equal Opportunity/Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources. EEO is the Law: https://www.eeoc.gov/sites/default/files/migrated_files/employers/poster_screen_reader_optimized.pdf

Keywords: Mission Regional Medical center, Harlingen , Medical Review Coord. - Social Service - Full Time - Days, Other , Harlingen, Texas

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