Medical Review Coord. - Social Service - Full Time - Days
Company: Mission Regional Medical center
Posted on: June 6, 2021
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
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.
Reviews admissions within 24 hours excluding holidays and
weekends and prepares for daily Case Management meetings.
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.
Reviews payor information and perform utilization reviews as
necessary for admission authorization and approval for continuation
Completes and submits authorization requests in a timely manner
as requested. Enters all authorizations and status of accounts into
the hospital-wide tracking system.
Maintains active file of denials and reports status to the
Director as requested.
Assists in preparing accounts for the appeal process by tracking
deadlines, reviewing clinical information, writing appeal requests
generating and submitting new TAR's.
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.
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.
- Performs other duties as assigned or required.
Master of Public Health (MPH) or post-graduation in a related
health care field is required.
Medical Graduate, Dental Graduate required.
- Knowledge of Clinical Pathophysiology and Pharmacology
ECFMG Certification And/or Bachelor's or higher from a US-based
accredited institution in a Health and Human Services field is
Utilization Review/Case Management experience is highly
1+ year of clinical experience in acute care setting
Excellent written and verbal communication skills. Excellent
critical thinking skills.
Excellent interpersonal skills to build effective partnering
relationships with physicians, nurse staff, coding staff and
hospital management staff.
Ability to work independently in a time-oriented
- 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
Keywords: Mission Regional Medical center, Harlingen , Medical Review Coord. - Social Service - Full Time - Days, Other , Harlingen, Texas
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