Description
*** 24 hours per week ***
Summary of Position:
The Utilization Review Coordinator provides routine clerical support, answers phones, routes callers and relays messages to Case Management/Social Services Staff. This position manages all departmental documents and ensures availability of supplies and the maintenance of equipment. This position is responsible for organizing and supporting the efforts of the utilization review process of the Case Management department through tracking, documenting, and informing staff of authorizations, denials and all other communication from insurance companies. The Utilization Review Coordinator supports the Case Management staff in discharge planning by gathering patient information in the medical record and faxing, and/or calling DME and/or higher or lower level of care facilities.
Qualifications
Education:
• High School Diploma or GED
Experience:
• Previous experience with the authorization process and with insurance companies required.
• Previous computer experience and database management preferred.
• In compliance with patient safety standards, must be able to effectively communicate in English; Bilingual abilities preferred.
Knowledge/Skills/Abilities:
• Understanding of authorization, billing, and familiarity with various payors
• Proficiency in computer skills and relevant software; database management experience required.
• Strong communication skills
• High attention to detail and strong organizational skills required.
• Maintain confidentiality.
Certifications/Licensure:
• Current CPR/BLS certification by the American Heart Association (BLS for the Healthcare Provider) or ability to obtain prior to start date
Physical Demands
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• While performing the duties of this job, the employee is frequently required to walk, stand, sit, and talk or hear.
• The employee is occasionally required to use hands to finger, handle, feel or operate objects, tools, or controls; and reach with hands and arms.
• The employee is occasionally required to climb or balance; stoop, kneel, crouch, or crawl.
• Specific vision abilities required by this job include close vision, color vision, and the ability to adjust focus.
• Lifts, positions, pushes and/or transfer patients.
• The employee must occasionally lift and/or move up to 50 pounds.
Working Conditions
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• Routine Hospital/Healthcare & Office/Administrative conditions.
• Contact with patients and guests under a wide variety of circumstances.
• Regularly exposed to the risk of bloodborne diseases.
• Exposure to infections and contagious disease.
• Exposed to hazardous anesthetic agents, body fluids and waste.
• Subject to hazards of flammable and explosive gases.
• Subject to varying and unpredictable situations, including the handling of emergency or crisis situations.
• Subject to pressure due to irregular hours, frequent interruptions and stressful situations due to multiple demands.
• Occasional travel to various health system locations.
Essential Functions
1. Provides consistently exceptional care at all times.
2. Answers telephones, initiates phone calls to payors, DME companies and higher or lower level of care facilities, routes callers, takes messages and provides routine information to callers.
3. Utilizes the Fax/copy Machine and Trace. Fax through Epic
4. Ensures that all messages are relayed to Case Managers, Social Workers and Director in a timely manner.
5. Supports Case Management Staff in Utilization review, denial management and discharge planning:
a. Tracks authorizations on spreadsheet and documents authorization information in Epic. Informs Case Manager of authorization information and when the next review is due.
b. Tracks Condition Code 44 information and informs Department Director and billing personnel.
c. Obtains denial information, informs Case Manager for appeal information, and submits appeal information. Tracks denial activity and documents in denial and appeal information in Epic.
d. Assists Case Manager in ordering DME and discharge planning. Provided patients with various mandatory Medicare letters when necessary.
e. Tracks transfers to CVMC for procedures that Barton is unable to perform and communicates to billing staff of such transfers.
f. Prepares and manages the patient's medical record. Ensures accurate and timely management of information.
g. Prepares medical record for utilization review to payors. DME companies and for lower and/or higher level of care transfers.
6. Performs routine clerical duties.
7. Files reports and other department records accurately.
8. Ensures supplies are available.
9. Ensures equipment is maintained. Able to troubleshoot equipment problems.
10. Responds to the needs of the department by performing other duties, as necessary.
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