MetroPlus Utilization Review/Management Coordinator I

MetroPlus Utilization Review/Management Coordinator I Department

UTILIZATION MANAGEMENT

Location Manhattan Job

ID134784

Civil Service ClassificationNon Competitive Hire In Rate$112,351.00 (for employees new to HHC) Salary Range$112,351.00 - $112,351.00 Pay FrequencyYear Full/Part TimeFull-Time Regular/TemporaryRegular Regular ShiftN/A About NYC Health + Hospitals MetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth's network includes over 27,000 primary care providers, specialists and participating clinics. For more than 40 years, MetroPlusHealth has been committed to building strong relationships with its members and providers.

Purpose of Position:

Working exclusively at MetroPlus, the MetroPlus Utilization Review/Management Coordinator, determines the appropriateness of admission, quality of care, and medical necessity of a patient's course of treatment throughout the patient's continuum of care. Monitors the quality of care, to ensure that it meets established standards. Ensures optimal utilization of resources, service delivery, and compliance with external review requirements and applicable state and federal rules and regulations for better outcomes and improved patient experience. All personnel perform related work. Work Shifts 9:00 A.M - 5:00 P.M Duties & Responsibilities Performs assigned duties related to analysis, review, and quality assurance of patient documentation.

Examples of Typical Tasks:

1. Analyzes and reviews patient/medical records holistically (retrospective, concurrent and prospective review of services) for medical necessity and appropriateness, and provides documentation and supporting evidence for Fair Hearing requests or external reviews to defend denial determinations. 2. Identifies and reports concurrent and/or retrospective trends and patterns of care which deviate from established norms. 3. Consults with medical, nursing and other staff involved in treatment to clarify concerns and secure documentation, as required. 4. Performs utilization review for all services (Durable Medical Equipment (DME), Inpatient, Out of Network, Skilled Nursing Facility (SNF), etc.) from System and non-System providers. 5. Initiates action and/or works with Social Service Department to monitor timely discharge planning. 6. Excerpts requested medical information from records for Utilization Review Management, Quality Management, and other committees and may otherwise participate as a member of the committee(s). Develops and maintains liaison with government and employees, third party payers, and Utilization Review agents. 7. Maintains appropriate files and other clerical records, to ensure timely review and processing of records. Prepares special Utilization Management reports, as required. 8. Participates in special studies relating to Utilization Review Management and Quality/Management. 9. Keeps informed of changes in regulations, procedures and treatment standards prescribed by the hospital, regulatory and/or reimbursement agencies. 10. Participates in designing quantitative measures and procedures by which program efficiency and cost - effectiveness can be audited, and participates in the evaluation audits. 11. Participates in internal/external quality assurance/performance improvement (QA/PI) activities and programs, facility-wide training, staff meetings, and relevant health care events, as required. 12. Ensures ongoing compliance and maintenance of the NYC Health + Hospitals policies with national standards and other applicable external regulatory requirements and guidelines. 13. Performs other related duties, as directed.

Minimum Qualifications Qualification Requirements:

1. Valid New York State license and current registration to practice as a Registered Professional Nurse issued by the New York State Education Department (NYSED); and, 2. Two (2) years of experience in a hospital or clinical setting in a capacity which provides thorough understanding of medical diagnosis, symptoms and treatment concepts; or one (1) year of experience in Utilization/Quality Management; or, 3. A satisfactory equivalent of education, training and experience. Benefits NYC Health and Hospitals offers a competitive benefits package that includes: Comprehensive Health Benefits for employees hired to work 20+ hrs. per week Retirement Savings and Pension Plans Paid Holidays and Vacation in accordance with employees' Collectively bargained contracts Loan Forgiveness Programs for eligible employees College tuition discounts and professional development opportunities College Savings Program Union Benefits for eligible titles Multiple employee discounts programs Commuter Benefits Programs