Utilization Review Coordinator

Cayuga Health and its affiliates are the region's leading healthcare system and most trusted providers of integrated health services, empowering our people in our mission to equitably improve the well-being of the communities we serve. Our commitment to providing extraordinary healthcare begins with our team of extraordinary professionals who are continuously discovering clinical innovations and enhancing access to the most up-to-date facilities, equipment, technologies, and research protocols. Cayuga Health's commitment to our employees includes competitive compensation, comprehensive employee benefits programs, and the opportunity to explore and build a career in healthcare through our many professional development programs.

Utilization Review Coordinator

Cayuga Health System seeks a motivated and experienced individual to join the Clinical Resource Management Team in the role of Utilization Review (UR) Coordinator. The UR Coordinator monitorsdaily activities and utilization management functions across the system in accordance with the goals and
objectives of the CHS Utilization Review Plan. UR Coordinator maintains knowledge of CMS Conditions of Participation for Utilization Review and
functions as a resource for the Case Management team on issues involving appropriateness of admission, level of care determinations, and the issuance of Hospital Issued Notices of Non-Coverage (HINNS). The UR Coordinator supports the UR Committee - preparing/presenting data and documents
as indicated. The UR Coordinator monitors medical necessity denials and facilitates peer-to-peer discussions, generating technical and medical necessity appeals as indicated per payer requirements.The UR Coordinator collaborates with provider offices and surgical scheduling to assure appropriate
authorizations and provides guidance as indicated to network partners and affiliates. The UR Coordinator also maintains knowledge of Swing Bed PDPM reporting and billing including entering appropriate HIPPS codes into the CMC billing system for submission.

Roles and Responsibilities:

• Demonstrates knowledge of medical necessity criteria and guidelines. Assist in the prospective,
  concurrent, and retrospective review of clinical cases to identify the most appropriate level of
  care based on nationally recognized criteria and standards of care.
• Monitors patient status, collaborating with patient access and providers to ensure alignment
  with physician orders.
• Participates in the analysis of Utilization trends and makes recommendations as indicated.
• Serves as a resource for the CRM team, and system at large, in daily concurrent review activities.
• Assists Director in the education of physician offices related to trends found in the surgical
  authorization process and related to authorization standard requirements communicated from
  third party payers.
• Implements and oversees the Clinical Resource Management medical necessity denial process.
  Assures ongoing tracking and trending of denial information and appeal activities.
• Maintains current knowledge of regulatory and compliance requirements for utilization
  practices, policies and procedures.
• Maintains accountability for the utilization management process across the system.

Required Skills and Experience:

• Education - Graduation from accredited nursing program. BSN in nursing preferred.
• Experience - Minimum 2 to 3 years' experience in an acute care hospital setting or equivalent health
  care experience. Knowledge of federal, state and accreditation standards. Strong written and verbal
  communication, organization, critical thinking and problem solving skills required.
• Licensure - Current unrestricted NY state RN licensure.

Preferred Skills and Experience:

• Graduate of an Accredited school of nursing, BSN preferred

Physical Requirements:

• Repetitive use of hands and fingers (e.g., Use of computer keyboard); may require lifting and carrying light loads (up to 40 lbs), including boxes, equipment, IV solutions and stooping and kneeling (e.g., to pick up items from the floor, to remove and replace items on lower shelves and to file documents in lower file drawers); sitting, walking, or standing for long periods of time may be necessary; must be able physically to operate the equipment used for the job.

Location and Travel Requirements:

• Onsite at 101 Dates Dr, Ithaca NY 14850
• Less than 25% Travel
• One 12 hour shift per week with some weekend and holiday requirements

Pay Range Disclosure:

• $83,280 to $98,280 annually based on experience

Cayuga Health System and its affiliates are committed to treating all patients, providers, staff and volunteers equitably and with dignity, ensuring the highest levels of safety, care and respect, and striving to recognize and overcome biases and policies that contribute to disparities in healthcare access, equitable care and positive health outcomes for all.

We are proud to be an Equal Employment Opportunity employer, supporting the growth and health of our employees and community by embracing the rich diversity, needs and circumstances of all peoples and prioritizing opportunities to build a diverse and inclusive workplace. We do not discriminate based upon race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable protected characteristics.

If you require reasonable accommodation to complete a job application, pre-employment testing, a job interview or to otherwise participate in the hiring process, please contact the Cayuga Health Talent Acquisition team at .