Utilization Review Coordinator

2 days ago

Manila, National Capital Region, Philippines Health Business Solutions Full time ₱300,000 - ₱600,000 per year

Utilization Review Coordinator

JOB SUMMA

RYWe are seeking a skilled Utilization Review Coordinator (URC) to oversee patient insurance certification, compliance with governmental regulations related to hospital stays, and the prevention of denials. Embedded within our utilization review management platform are clinical criteria guidelines, streamlining the review and documentation process. The Utilization/Risk Management department conducts perspective, concurrent, and retrospective reviews for authorization of Levels of Care (LOCs) and services, engaging with Program Managers, reviewing medical necessity records, and liaising with individuals and their families when necessary. Additionally, the department handles billing and payroll function

**s.

PRIMARY RESPONSIBILIT**

  • IESEvaluate patient records to assess severity of illness and intensity of servi
  • ce.Apply medical necessity screening criteria and clinical knowledge to ensure appropriateness of admissions and length of sta
  • ys.Conduct initial admission, continuing stay, and 23-hour observation reviews for all patien
  • ts.Manage case reviews in the electronic utilization review syst
  • em.Collaborate with payor sources to communicate clinical information and secure hospital reimburseme
  • nt.Consult with physicians and nursing sta
  • ff.Participate in interdisciplinary care rounds for effective communication with the care te
  • am.Use escalation pathways to resolve identified issu
  • es.Document all activities and interactions in the electronic utilization review reco
  • rd.Enhance customer satisfaction among patients, families, physicians, internal and external partners, payors, and vendo
  • rs.Submit Initial and Concurrent Authorizations to insurance compani
  • es.Verify client insurance coverage for authorization submissi
  • on.Coordinate with insurance companies to resolve billing or authorization issu
  • es.Communicate Billing and Payroll questions from Program Managers and ensure accurate documentation before billing clai
  • ms.Review Service Verification Forms and Time sheets to ensure precise payroll processi
  • ng.Participate in state and local audi
  • ts.Adhere to policies, procedures, regulations, and standards governing the agen
  • cy.Maintain strict confidentiality according to Federal and State guidelin
  • es.Uphold the Professional Code of Ethi
  • cs.Other duties as assign

**ed.

QUALIFICAT**

IONSRequi

  • red:Bachelor's degree in nursing, physical therapy, medical technician, HIMS, or a related medical fi
  • eld.Managed Care or Health Plan experie
  • nce.Detail-orien
  • ted.Effective oral and written communication ski
  • lls.Moderate computer proficiency – Microsoft Office Su
  • ite.Team-oriented appro
  • ach.Independent functioning and auton

omy.Strongly preferred qualificati

  • ons:Previous experience in utilization review/managem
  • ent.Experience with InterQual and/or Milliman Care Guideli

nes.

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