UTILIZATION REVIEW COORDINATOR at Campbell County Health – Gillette, Wyoming

ABOUT CAMPBELL COUNTY HEALTH

Campbell County Health (CCH) is more than just a hospital—we are a comprehensive healthcare system serving northeast Wyoming. Our organization includes Campbell County Memorial Hospital, a 90-bed acute care community hospital in Gillette; Campbell County Medical Group, featuring nearly 20 specialty and primary care clinics—including locations in Wright and Hulett; and The Legacy Living & Rehabilitation Center, a long-term care facility.

To be responsive to our employee’s needs we offer:

• Generous PTO accrual (increases with tenure)
• Paid sick leave days
• Medical/Dental/Vision
• Health Savings Account, Flexible Spending Account, Dependent Care Savings Account
• 403(b) with employer match
• Early Childhood Center, discounted on-site childcare
• And more! Click here to learn more about our full benefits package

JOB SUMMARY

The Utilization Review (UR) Coordinator focuses on integrating care management, social services, discharge planning, utilization review and pre- and post- hospital services to ensure clinical efficacy and best outcomes for our patients. The UR Coordinator works to ensure the provision of quality health care along the continuum of care, decreases fragmentation, enhances the patient’s quality of life, efficiently uses patient care resources, maximizes cost containment opportunities, and improves successful post-hospitalization transition care. The UR Coordinator guides the integrated team in the functions of care coordination, facilitation of referrals, education, discharge planning, utilization management, and advocacy. This position reports to the department head.

ESSENTIAL FUNCTIONS

• Completes assessment of patient and family in timely manner. Specific attention is paid to readmissions, at risk and/or resource intense inpatients. Patients identified with complex psychosocial, financial, or discharge issues will be consulted on with the Manager of Case Management and Social, Social Workers, Nurse Case Managers and/or Case Managers.
• Assess patient/family adaptation to illness/disability and capacity to provide for patients care needs. Completes assessment of patient’s clinical course to provide ongoing pt. care coordination. Verifies patient’s needs for acute hospital level of care. Identifies obstacles to discharge.
• Collaborates with physicians, nurses and other disciplines involved with care of the patient to foster a coordinated approach to patient care. Communicates with physician regarding the medical plan of care, anticipated discharge, and consideration of alternative setting.
• Completes utilization review functions including medical necessity with designated criteria software.
• Facilitates and impacts process issues to avoid delays in patient care. Intervenes with appropriate individual/departments regarding delays in service that may have an impact on quality of care and/or length of stay. Provides feedback to supervisors regarding delays to constantly improve the process.
• Utilization review of the patient’s hospital stay is done in a timely manner and is documented in Midas. Clinical review is assessed to determine if inpatient admission/continued stay has been met.
• Clinical is provided to insurance agencies/payer in a timely manner. All payor questions are answered.
• Collaborates with patient accounting, eligibility specialist and outpatient billing to optimize captured services.
• Functions as a liaison to external agencies including home health/hospice, rehab/skilled facilities, assisted living/long term care facilities, public health, and any other identified needs throughout hospitalization.
• Maintains required and concise documentation for patients including physical and functional limitations, psychosocial characteristics, plan of care to address post-hospital, treatment, and post treatment care needs, educational needs, and involvement in planning for care of patient and family, family/social support systems, financial, economic, and discharged needs. Initiates referrals to disciplines with appropriate paperwork.
• Focuses on the patient’s goals and preferences and includes the patient and caregiver/family as active partners in the discharge planning for post-discharge care. The discharge planning process and plan must be timely, consistent with the patient’s goals for his/her treatment preferences, ensure effective transition of the patient from hospital to post-discharge care with effective arrangements made prior to discharge, and reduce the factors leading to preventable hospital readmissions.
• Seeks peer and supervisor consultation regarding problematic cases or cases demonstrating deviations from the plan of care.
• Provides service excellence to all customers.
• Maintains professional standards related to clinical practice, staffing, and continuing education.
• Practices fiscal responsibility and accountability.
• Actively participates in hospital committees, CQI teams, and Quality Improvement Program.
• Coordinate and leads the Utilization Management Committee.
• Maintains a clean and safe environment.
• May be required to work on other nursing units according to distribution of staff and patients.
• Complies with the hospital’s Corporate Compliance Program including, but not limited to, the Code of Conduct, laws and regulations, and hospital policies and procedures.
• Must be free from governmental sanctions involving health care and/or financial practices.
• Other duties as assigned. This list is non-exhaustive.

JOB QUALIFICATIONS

• Education
  • Bachelor’s degree in Nursing
• Licensure
  • Wyoming RN license.
    • Licensed professionals must strictly adhere to the ethical code of their respective discipline.
• Certifications required
  • See Cardiopulmonary Resuscitation Certification Policy and Certifications/Education Requirements Policy.
• Experience
  • At least five (5) years of experience in the healthcare field required; previous utilization review experience is preferred.