Utilization Review Coordinator (8 AM - 5 PM)

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Utilization Review Coordinator (8 AM - 5 PM)

@ VieMed

Essential Duties and Responsibilities:

Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions of this position. 

• Conduct clinical reviews of patient medical records and referral documentation to evaluate whether documentation supports prescribed therapies, ordered equipment, supplies, and applicable coverage requirements
• Review physician orders, progress notes, histories and physicals, diagnostic information, test results, hospital records, and other relevant clinical documentation relevant to the referral
• Identify missing, incomplete, inconsistent, or unclear clinical documentation and communicate specific documentation deficiencies or clarification needs to the appropriate parties.
• Apply professional nursing knowledge when evaluating diagnoses, symptoms, treatment history, medical-necessity indicators, and the relationship between documented clinical findings and the requested therapy or equipment
• Provide recommendations regarding referral readiness, additional documentation requirements, and appropriate next steps based on clinical chart-review findings.
• Evaluate clinical documentation against applicable Medicare, Medicaid and commercial payer coverage criteria prior to submission for reimbursement or
• Maintain compliance with applicable governmental regulations, payer requirements and VieMed Intake, Billing and Compliance procedures
• Accurately document clinical review findings, identified deficiencies, recommendations, and referral status within the designated computer system
• Escalate complex clinical questions, documentation concerns, potential compliance issues and other matters requiring additional review to the Intake Manager, Intake Supervisor or appropriate leadership position
• Perform other responsibilities and projects assigned

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Qualifications:

Qualifications

• Current, active Registered Nurse (RN) license in good standing
• Clinical nursing experience with demonstrated ability to review medical records, interpret physician documentation, and apply professional nursing judgement.
• Ability to apply nursing knowledge and sound clinical judgment when evaluating the completeness and clinical relevance of medical documentation
• Ability to read and interpret diagnoses, physician orders, progress notes, diagnostic testing, treatment plans, and other clinical records
• Working knowledge of medical terminology and common respiratory and DME therapies
• Understanding medical insurance concepts and the ability to learn and apply Medicare, Medicaid, and commercial-payer documentation requirements
• Strong attention to detail with the ability to identify incomplete, conflicting, or insufficient documentation and communicate the specific gap clearly
• Effective written and verbal communication skills, including professional communication with physicians, healthcare providers, insurers, patients, colleagues, and leadership
• Ability to manage multiple chart reviews, prioritize workload, meet established turnaround expectations, and maintain accurate documentation
• Ability to work independently, exercise sound clinical judgement, while collaborating effectively across operational departments
• Proficiency with electronic medical records, patient/referral databases, and Microsoft Office applications, including Outlook, Word, and Excel
• Proficiency with electronic medical records, patient and referral databases, and Microsoft Office applications, including Outlook, Word, and Excel
• Demonstrated professionalism, accountability, , initiative, and consistent productivity
• Availability to work Monday through Friday during an agreed-upon shift. Weekend work, overtime, or on-call coverage may be required based on business needs

Access to Protected Health Information (PHI)

• This position requires the employee to handle Protected Health Information (PHI) for duties related to document and report preparation. Policies and procedures must be strictly followed to protect PHI as required by the HIPAA Privacy Rule.

Working Conditions

• This position will work in an office environment.

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How to Apply:

Apply online at: https://www.viemed.com/corporate-careers/ 

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