The Utilization Review Coordinator (URC) is responsible for initial clinical review. URC may approve requests for admissions, procedures, and services that meet clinical review criteria. For homebound services, the URC may approve requests when a licensed social worker request such services and the referral does not meet clinical review criteria. The URC may also evaluate cases as a secondary reviewer for certification or non-certification, as the staff member with the same license and category as the requested provider. This process will streamline the decision-making process within the organization.

1. Discuss the cases with the psychiatrists, psychologists, or social workers as appropriate to determine medical necessity criteria for authorizations.
2. Conduct prospective, concurrent, retrospective review and secondary reviews for homebound services.
3. As a secondary reviewer, URC can only evaluate cases that do not meet clinical criteria in the initial review requested by a provider in the same licensed and category. The URC is able to evaluate cases as a secondary reviewer when the initial review was not conducted by the same individual.
4. Evaluates the quality, medical necessity, and services provided.
5. Provide guidance to the non-clinical staff as needed.
6. Provide written notice to the member and providers via fax, mail and/or secure email.
7. Maintain a registry of all cases by facility/providers and account in the UMP platform.
8. Issues the services authorizations after the review is completed.
9. Maintains up-to-date utilization review documentation in the designated platforms.
10. Visits the hospital facilities or receives the documentation via fax and perform the initial review of the clinical information.
11. Discuss the cases with the psychiatrists, psychologists, or social worker as appropriate to discuss medical necessity criteria for authorizations.
12. Maintains the daily census of the assigned facilities.
13. Responsible for making sure that the peer-to-peer discussion takes place.
14. Available to travel throughout Puerto Rico.
15. Issues the services authorizations after the review is completed.
16. Maintains updated utilization review documentation in the platforms.
17. Documents and reports in the system the ineligible cases.
18. Provides the daily utilization data of the facilities assigned.
19. Maintains a registry of all cases by facility/providers and account in the UMP platform.

EEO Statement

All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion, and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws. We believe that diversity and inclusion among our teammates is critical to our success.

Notice

At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skillset and experience with the best possible career path at UHS and our subsidiaries. We take pride in creating a highly efficient and best in class candidate experience. During the recruitment process, no recruiter or employee will request financial or personal information (Social Security Number, credit card or bank information, etc.) from you via email. The recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc. If you are suspicious of a job posting or job-related email mentioning UHS or its subsidiaries, let us know by contacting us at: https://uhs.alertline.com or 1-800-852-3449.

• Master's in social work, Psychology, Psychological Counseling, Counseling, Psychiatric Nursing, or bachelor's in nursing.
• Unrestricted valid and current active license for Social Work, Psychology, Counseling Psychology, Psychiatric Nursing, or bachelor's in nursing to practice in the Commonwealth of Puerto Rico
• Professional associating membership (colegiacion): Valid membership for Social Work and Psychiatric Nursing
• Two or more years of experience in clinical direct services.
• Basic knowledge of psychotropic agents required.
• Basic in computers: Microsoft Office, Outlook, Internet
• Bilingual (Spanish and English)