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Coordinates and supervises all phases of Utilization Review and Social Services. Plans and directs the operational activities of the Utilization Review and Social Services Departments, assuming responsibilities for quality and productivity of utilization review and discharge planning.: Coordinates, facilitates, and integrates high quality, cost-effective care delivered to individuals or groups of patients across an episode of illness or throughout the continuum of care. Assesses, plans, intervenes, and evaluates clinical outcomes. Performs concurrent review of patients' medical records for medical necessity, appropriateness of setting, assessment of the quality of medical care, and the tracking/trending of these activities. Directs the patient complaint and quality management program. Monitors utilization activities and tracks and reports data. Maintains relationships with physicians, department heads, administrators, and clinical coordinators to support intra-departmental goals. Supervises staff.

Medical Claims Review Manager

Manages the medical claims review staff to ensure process improvement and quality in claims review. This position typically requires a Bachelor’s degree with five years of medical review experience. This position may require a nursing degree.: Manages the medical claims review staff to ensure process improvement and quality in claims review. Translates benefit plan language (Summary Plan Descriptions) into standard review program procedures. Interfaces with clients to conduct/manage random sample reviews to determine medical claims processing accuracy and timeliness. Works with clients to coordinate operational reviews to assess administrative processes and controls. Reviews company claims, eligibility, provider, and medical management systems to identify issues affecting quality and productivity. Documents findings and write follow-up reports. Provides planning, organizing and budgeting for the department. Develops, administers and reports service quality indicators for each team under supervision. Recommends and implements innovative strategies to retain members, contain medical costs and improve efficiency. Hires, trains, coaches, counsels and evaluates performance of direct reports. This position typically requires a Bachelor’s degree with five years of medical review experience. This position may require a nursing degree.

Utilization Review/Quality Assurance Director

Serves as an information coordinator for the hospital-wide quality assurance program. Directs development of monitors, including generic screens, to assess the quality of care provided to patients.: Supports the overall quality assurance reporting system to assure that information is being channeled to appropriate oversight committees. Provides consultation to health care providers as needed to facilitate problem-focused studies of patient care, which may include advice and support for clinical/legal implications of quality issues. May assume Risk Management responsibilities. May supervise several employees.

Utilization Review Manager

Manages the utilization review function to ensure accurate and timely prior authorization of designated healthcare services, concurrent review, and retrospective review activity. Performs regular data analysis of hospital census, authorization information and medical cost reports to identify variances and root causes so that areas of focus may be identified and resources may be appropriately deployed.: Manages the utilization review function to ensure accurate and timely prior authorization of designated healthcare services, concurrent review, and retrospective review activity. Manages a department responsible for the determination of medical necessity and appropriateness of care based on predetermined criteria and/or guidelines. Plans, organizes, implements and evaluates departmental outcomes. Performs regular data analysis of hospital census, authorization information and medical cost reports to identify variances and root causes so that areas of focus may be identified and resources may be appropriately deployed. Prepares and manages the departmental budget. Hires, develops and motivates a qualified utilization review department staff. Ensures that benefits and policies are properly interpreted and that care is rendered in the most appropriate site of service with a focus on quality care and cost efficient outcomes. Assures timely response to provider requests for services per department standards. Conducts regular clinical reviews for utilization management activities, based on guidelines and standards for patients in a variety of settings. A Registered Nurse with clinical and managed care experience is typically required for this position.

Utilization Review/Quality Assurance Coordinator

Interprets and implements quality assurance standards in clinical area or hospital to ensure quality care to patients. Ensures appropriate care is provided to patients. Reviews quality assurance standards, studies existing policies and procedures, and interviews personnel and patients to evaluate effectiveness of quality assurance program. May report to Quality Assurance Head Hospital or a similar high-level position. Position typically requires a bachelor's degree in the field of nursing.: Serves as a professional resource to nursing staff. Writes quality assurance policies and procedures. Reviews and evaluates patients' medical records, applying quality assurance criteria. Selects specific topics for review, such as problem procedures, drugs, high volume cases, high risk cases, or other factors. Compiles statistical data and writes narrative reports summarizing quality assurance findings. May review patient records, applying utilization review criteria, to determine need for admission and continued stay in hospital. May oversee personnel engaged in quality assurance review of medical records.

Utilization Review Supervisor

Plans, organizes, and supervises, under general direction, the activities of the Utilization Review unit of a hospital. Ensures compliance with reimbursement rules of third-party payers. Performs the more complex utilization review work. Monitors and ensures hospital compliance with Medic-Cal, Medicare, and insurance reimbursement policies, the maintenance of patient care quality, and the maximizing of reimbursements for services provided. Reports to the Hospital Quality Assurance Manager.: Plans, organizes, and supervises the staff of the Utilization Review unit. Reviews and analyzes government and accrediting agency standards governing admissions, treatment, and continued stay of patients. Develops policies and procedures for adherence to governmental and accrediting agency standards. Coordinates the work of the Utilization Review staff with medical staff to ensure appropriate and timely patient care action and to maximize reimbursement. Analyzes individual patient records to determine appropriateness of admission. Reviews patient treatment plans for adherence to established criteria and standards. Refers cases that fail to meet criteria to the Patient Care Review Committee for review and course of action. Conducts studies and prepares reports for the review committee, medical staff, and administration. Serves as review committee liaison with other committees to coordinate formulation of policy and procedures. Explains procedures and documentation requirements to medical staff, managers, and other hospital personnel. Interviews, selects, trains, and evaluates Utilization Review staff.

Utilization Review Coordinator

Analyzes and evaluates patients' medical records, charts, computer printouts, and support documents to ensure criteria for admission to health-care facility, treatment, and length of stay are met, and to ensure cost effective utilization of resources, according to established criteria: Analyzes insurance, governmental, and accrediting agency standards to determine criteria concerning admissions, treatment, and length of stay of patients. Reviews admission records, medical records, charts, and supporting documentation to establish reason for admission, diagnosis, and length of stay. Approves admission or refers case to facility utilization review committee for review and course of action when case fails to meet admission standards. Determines necessity, cost effectiveness, and documentation of treatment and care provided, utilizing coding and classification manuals, insurance, governmental, and accrediting agency regulations and standards to determine that established criteria for admission and care have been met. Reviews pre-certification request and application for admission, calculates estimated cost of prescribed medical treatment, prepares required paperwork, and approves admission based on predetermined criteria for pre-hospitalization request from health providers or insurance subscribers. Monitors health care treatment provided to patient during patient's stay in medical facility and compares inpatient medical records to established criteria and confers with medical personnel and other professional staff to determine legitimacy of treatment and length of stay, to ensure services are within prescribed limitations, to ensure availability of future benefits, and to guard against potentially abused medical procedures and diagnoses. Retrieves medical data from medical records, charts, and computer, and abstracts required data from records to use in compiling reports and for statistical purposes. Acts as liaison for insurance provider, contractors, and subscribers to explain and interpret provisions of contractual agreements and health benefits and to process complaints. May assist review committee to plan and conduct federally mandated quality assurance reviews. May direct activities of utilization review staff. May conduct telephone reviews to ensure that patient admission to provider facility meets established criteria. May interview patient to obtain medical history information and determine necessity of treatment.

Medical Claims Review Nurse

Resolves, audits, and processes claims for clinically related issues to ensure accuracy of claims payment, supporting the Claims Administration Department. Maintains contact with community hospitals and providers, reviewing, processing, and auditing claims for payment and appropriateness of charges and pursues adjustments as warranted. Typically requires licensure as a Registered Nurse and at least one year of experience in utilization review or a managed care setting.: Screens, audits, and processes claims of specific criteria for appropriate payment. Establishes effective ongoing relationships with community hospitals and providers. Participates in educational, provider relations, and contracting meetings with providers to address medical claims payment issues. Visits the providers as necessary to compare billed charges to the medical record. Provides support to the Accounting Department in determining financial liability for out-of-plan medical services. Performs special projects, reconciliations, research, and analysis relating to the utilization and cost of medical services. Works closely with various departments to coordinate the flow of information involving payment of medical bills and analyses of financial liability. Ensures compliance with contractual obligations on claims payments. Documents findings and writes follow-up reports. Recommends and implements innovative strategies to retain members, contain medical costs, and improve efficiency.

Banking Loan Review Analyst

Evaluates quality of commercial loans and assigns risk rating indicating borrower's financial strength and probability of loan repayment. Selects loans to evaluate for credit risk according to factors, such as geographical location, and type and amount of loan. : Records data on worksheet, such as purpose of loan, balance, collateral, and repayment terms. Verifies value of collateral by calling appraisers and auction houses for current value of machinery and equipment. Calls real estate appraiser for new real estate appraisal. Evaluates information to determine whether lending officers have stayed within guidelines of lending authority, if loan is in compliance with banking regulations, and if required documents have been obtained. Identifies problem loans and describes deficiencies. Writes summary of analysis and reasons for assigning adverse risk rating. May act as senior analyst and coordinate data collection and evaluations of credit quality of commercial loans, and present loan review information and report to management.

Analyst Loan Review

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