RN Utilization Review Coordinator, Full-time

Denial Management

• 1.
• Identify, track, and manage utilization review denials related to admission status, level of care, length of stay, and medical necessity.
• 2.
• Draft, write, and submit denial appeal letters using clinical judgment, medical record review, applicable payer, CMS, and regulatory guidelines to support medical necessity determinations.
• 3.
• Collaborate with physicians, case managers, physician advisors, and leadership to obtain supporting clinical documentation, physician statements, and peer‑to‑peer review input for appeals to support denial resolution.
• 4.
• Monitor denial outcomes, appeal success rates, and payer trends; analyze root causes and provide feedback, education, and recommendations to reduce future denials.
• 5.
• Maintain accurate documentation of denials and appeals in accordance with hospital policy and regulatory requirements.

Discharge Planning Support

• 1.
• When needed, collaborate with the Case Management team to support timely and safe discharge planning.
• 2.
• Serve as the patient advocates and enhances collaborative relationships with the healthcare team, physicians, patients, and families to maximize the patient’s and family’s ability to make informed healthcare decisions.
• 3.
• When needed, assist in identifying and addressing barriers to discharge, including durable medical equipment (DME), home health services, medications, and therapy need.
• 4.
• Reinforce patient and family education to promote successful transitions of care.
• 5.
• When needed, transmit Continuity of Care Documents to appropriate post‑acute providers to ensure follow‑up care.

Reporting, Compliance & Quality

• 1.
• Monitor, track, and analyze avoidable days and extended lengths of stay; identify contributing factors related to utilization, payer processes, discharge barriers, and system delays, and collaborate with Case Management, physicians, and interdisciplinary teams to support timely resolution.
• 2.
• Assist the Case Management Manager and Quality Director with data collection and analysis for quarterly and annual utilization review reports.
• 3.
• Participate in regulatory audits, surveys, and internal reviews related to utilization management.
• 4.
• Investigate and report adverse occurrences and trends related to utilization, discharge planning, or resource management.
• 5.
• Provide staff education related to utilization review processes, medical necessity, and resource utilization.

Professional Responsibilities

Must demonstrate high attention to detail, the ability to multi-task, prioritize, and have strong critical thinking skills to address issues that arise unexpectedly.

• 1.
• Must encompass the skill to follow through with tasks and situations while providing clear communication to others throughout the process.
• 2.
• Maintain a high standard of professionalism and ethical conduct in accordance with hospital policies and the Methodist Hospital for Surgery Code of Conduct.
• 3.
• Support and facilitate initiatives enhancing patient outcomes, patient satisfaction, and regulatory compliance.
• 4.
• Communicate effectively, professionally, accurately, and timely with all staff and patients.
• 5.
• Demonstrates the spirit of philosophy, mission, and values of the hospital through words and actions and implements them into departmental processes, programs, and the working environment 6.
• Perform other duties as assigned or required.

Minimum Requirements

Education

Bachelor of Science in Nursing preferred.

Certification, Licensure

Active RN license in Texas; current CPR certification. Case Management Certification(s) preferred.

Experience, Training, Knowledge

At least five years of experience with Case Management, Discharge Planning, and Utilization Review.