Utilization Review Coordinator

Description

Lexington Regional Health Center

Title: Utilization Review Coordinator

Effective Date: September 9, 2026

Supervisor: Director of Care Management and Social Services

Department: Nursing

FLSA Status: Non-Exempt

Principle duties and responsibilities

1. Coordinates the care and discharge planning of hospitalized patients from a
multi-disciplinary stand point.

2. Participates in multi-disciplinary rounding to include: provider rounds, daily huddle, weekly discharge planning meeting, etc.

3. May assist in coordinating patient discharges by ensuring health education management is provided to patients and their support systems, regarding post hospital care and may coordinate needed resources when applicable. 

4. Works to provide safe transitions from the hospital to home while ensuring patient safety, patient understanding of their care plan and future plans, along with reducing readmissions.

5. Works collaboratively with all aspects of patient care team to include various healthcare professionals, hospital departments, community resources and the patient.

6. Coordinates and collects quality data including call backs, swing-bed and Utilization Review. 

7. Assists with goals to reduce readmissions, over utilization of Emergency Room through chart reviews, process improvements and etc. Such as contacting patients after dismissal to ensure that the plan of care was understood and followed. (Medication reconciliation, future appointments are made and any patient questions are answered.)

8. Attends a participates organization Utilization Review Committee. 

9. Help assist patients and designated support system on preventive measures, disease management, health care management throughout the health system, etc.

10. Manages and intakes swing bed referrals. Communicates with multidisciplinary team to ensure patient centered holistic care and develop a multidisciplinary plan of care through IDT meetings. Ensure documenting of certification of stay and recertification’s. Complies with all swing-bed rules and regulations. May assist with swing-bed chart reviews. 

11. Maintains medical record documentation to accurately reflect care administered and patient's condition. Records all care information concisely, accurately and completely in a timely manner in the appropriate format and on the appropriate forms. 

12. Provides holistic support to patients and patient designated support system.

13. Assures medical criteria is met for admission to appropriate service by discussion with providers and reviewing documentation. 

14. Assist in Chart Review Audits for Utilizations Review Committee. 

15. Rotating for UR call to ensure appropriate UR coverage on weekends. 

16. Participates in patient care activities that could include blood exposure and risk to bloodborne pathogens (eg: lacerations, handling of blood-contaminated specimens, etc.) 

17. Responsible for safe bagging and disposal of biohazardous waste. 

18. Responsible for following safe-injection practices. 

19. Responsible for ensuring the environment meets appropriate governing body standards.

20. Ensure patients and visitors follow current infection control guidelines.

21. Responsible for proper collection, storage and labeling of biological specimens.

22. Maintains patient and staff safety through the use of patient safety tools (TeamSTEPPS, Just Culture, etc.).

23. Communicates all departmental concerns with the Director of Care Management and Social Services/or Chief Nursing Officer. 

24. Regular attendance at the assigned work location is required.

25. Performs all other duties as assigned.

Minimum knowledge, skills, and abilities

1. Knowledge and understanding of utilization review processes, medical necessity criteria, level-of-care determinations, and payer authorization requirements.

2. Ability to review clinical documentation and apply established criteria, such as InterQual or other organization-approved guidelines, to support appropriate admission status, continued stay, and discharge planning decisions.

3. Minimum of two years acute care, case management, utilization review, discharge planning, or care coordination experience preferred.

4. BLS certification required within six months of hire and/or orientation.

5. Knowledge of Medicare, Medicaid, commercial payer, and workers’ compensation authorization processes, including notification requirements, concurrent review, clinical documentation submission, and denial prevention practices.

6. Ability to maintain accurate, timely, and complete documentation in the electronic medical record and other required utilization review tracking systems.

7. Ability to maintain strict confidentiality and comply with HIPAA, organizational privacy standards, and all requirements related to protected health information.

8. Strong critical thinking, analytical, organizational, and problem-solving skills with the ability to prioritize multiple reviews, deadlines, and communication needs.

9. Ability to communicate professionally and effectively with providers, nursing staff, patients, families, insurance companies, workers’ compensation representatives, regulatory agencies, and members of the interdisciplinary care team.

10. Ability to complete reports, correspondence, clinical summaries, committee materials, and audit documentation at a professional level.

11. Ability to respond appropriately to inquiries, concerns, and complaints from patients, employees, payers, providers, and regulatory agencies.

12. Ability to effectively communicate and collaborate with individuals from diverse backgrounds while demonstrating professionalism, respect, and patient-centered advocacy.

13. Computer proficiency required, including use of electronic medical records, Microsoft Office applications, payer portals, and other software systems used for utilization review and care coordination.

14. Successful completion of required training related to standard precautions, transmission-based precautions, infection prevention, patient safety, and other competency requirements applicable to the position.

Working conditions

1. Works in a normal office work environment with little exposure to excessive noise, dust, temperature etc.  

2. Sitting, walking, and/or standing for up to 90% of work time when doing Utilization Review, Preauthorizing Orthopedic and Urology surgeries and Mental Health Assessments, etc.  Up to 20% of work time may push items weighing up to 50 pounds if needed. 

3. Comes in contact with a variety of isolation patients (up to 5% of work time), but seldom severe hazards. Follows the appropriate safety education given to prevent any at risk situations or environments.  

4. Spends up to 40% of day seated, completing paper/computer work. The rest of the 60% percent of the day is spent completing various patient-related activities, i.e. meeting with patients and caregivers. May take part in 1-2 meetings per day, whether in hospital, Emergency Room or Family Medicine Specialists clinic. Will need to ambulate around the hospital up to 30% of day to 700 feet to Family Medicine Specialists clinic. Stocks own shelves with information, lifting up to 7 pounds approximately 50 inches in height to 3 inches from floor. A cabinet contains overhead storage that may need accessed with materials 1-2 pounds in weight. 

5. Exposure to chemicals and other hazards related to patient care. Appropriate safety precautions, such as safety glasses, gloves, etc. must be used to minimize risk of injury.
6. Direct exposure to body substances during patient care activities and on contaminated surfaces such as patient equipment.

Management responsibilities

1. None.

Job description statements are intended to describe the general nature and level of work being performed by employees assigned to this job title. They are not intended to be a complete list of all responsibilities, duties and skills required.