The Utilization Review/Case Manager ensures maximum third-party payer coverage for patients, monitors medical records for documentation compliance, and improves the quality of medical record accuracy. Responsibilities include:
Conducting concurrent and retrospective reviews of patient records. Communicating with insurance carriers and healthcare staff. Performing pre-certification and certification of patient charts. Compiling reports for quality measures and utilization review statistics. Qualifications include an RN/LPN or RHIT degree, experience in acute care or Health Information Management, and knowledge of medical terminology and compliance regulations. The role requires effective communication, time management, and adherence to HIPAA standards.