The UM Coordinator contacts external case managers/managed care organizations for certification and recertification of insurance benefits throughout the patient's stay, and assists the treatment team in understanding the insurance company's requirements for continued stay and discharge planning. The UM Coordinator is responsible for having a thorough understanding of the patient's treatment through communication with the treatment team. The UM Coordinator advocates for the patient's access to services during treatment team meetings and through individual physician contact.
Case Management/Utilization Management
Review the treatment plan and advocate for additional services as indicated.
Promote effective use of resources for patients.
Ensure that patient rights are upheld.
Maintain ongoing contact with the physician, program manager, nurse manager, and various members of the team.
Collaborate with the treatment team regarding continued stay and discharge planning issues.
Advocate that the patient is placed in the appropriate level of care and program.
Interface with program staff to facilitate a smooth transition at the time of transfer or discharge.
Maintain documentation related to UR activities
Assure tracking of insurance reviews, and that reviews are completed in a timely manner.
Maintain statistical reports and prepare documentation of significant findings.
Communicate insurance requirements to all levels of staff.
Provide timely updates regarding patient status on log sheets that are prepared for daily meetings concerning admissions, reviews, and discharges.
Update the denial log statistics on an ongoing basis (at least weekly), and initiate appeals through telephone or written communication within 7 to 10 days of denial.
Consult with the business office and/or admission staff as needed to clarify data and ensure the insurance precertification process is complete.
Provide clinical information to managed care companies, insurance companies and other third party reviewers to establish the length of stay or number of certified days.
Coordinate with the insurance company doctor in appeals process and denials process.
1. Review assessment information.
2. Communicate with attending physician and program managers, and other providers of service, to assure continuity of care, efficiency, and effective transitions between levels of care.
3. Provide feedback to the attending physician and treatment team members concerning continuing certification of days/services.
4. Communicate with external reviewers and referral sources. Conduct external reviews and maintain documentation of interactions.
5.Ensure that third-party payers are notified of, or participate in, decisions about transitions between levels of care.