Utilization Review Specialist
We are hospitals and affiliated medical groups, working closely together for the benefit of every person who comes to us for care. We build comprehensive networks of quality healthcare services that are designed to offer our patients highly coordinated, personalized care and help them live healthier lives. Through collaboration, we strive to provide all of our patients and medical group members with the quality, affordable healthcare they need and deserve.
Under the direction of the Director/Manager of Case Management, the Utilization Review Specialist directs all back-office functions of the Case Management Department. Interfaces with all payors/providers requesting authorizations, medical records, and other specific information. Confirms completeness of reviews to payors. Directs concurrent denials to appropriate local staff. Assists the Lead Case Manager with coordinating schedules and assignments of Case Management Team. Provides clerical functions to the Case Management Department, ensuring smooth office operations.
Job Responsibilities/Duties
- Interfaces with all payors and providers requesting authorizations, medical records, and other specific information. Completes payor and provider request for missing or additional documentation. Logs all authorization requests to ensure that they are submitted the same day as requested. Forwards all managed care/payor questions, correspondences and authorizations to Director/Manager of Case Management (or designee). Ensures that all requests are handled appropriately and in a timely manner.
- Performs basic reception functions to ensure smooth office operations, including answering incoming calls, maintaining an accurate filing system, ensuring office supplies stocked to appropriate levels and office equipment serviced, copying forms and documents, etc. Types memos and other case management documents as assigned. Effectively uses computer programs. Accurately collects and documents all necessary and required information and activities into the appropriate computer systems.
- Clears all providers, such as home health, LTACH, SNF, board and care, prior to providing patient access. Directs providers where they need to go and ensures they get there in a timely manner. Ensures that all patient privacy guidelines/laws are followed.
- Maintains audits for timely completion of Utilization Reviews. Completes audits for retroactive reviews and provides same day summary to Director of Case Management. Ensures that all reviews are completed and received by the payor in a timely manner.
- Maintains status and oversees required performance improvement data/documents for current PI/Quality indicators. Cross references multiple sources of data, ensuring that information is in appropriate place in patient medical records. Accurately collects data and organizes graphs, PowerPoints, or needed presentation materials under the direction of the Leader of the Department and/or UR Committee members. Completes all assigned Performance Improvement tasks in a timely and accurate manner.
- Accurately collects data and organizes graphs, PowerPoints, or needed presentation materials under the direction of the Leader of the Department and/or UR Committee members.
Qualifications
Minimum Education: None.
Minimum Experience: Knowledge of utilization management required. Two (2) years works experience required. Must demonstrate customer service skills appropriate to the job. Computer literacy and proficiency. Excellent written and verbal communication skills. Ability to establish and maintain effective working relationships within the organization. Ability to multitask and maintain a work pace appropriate to workload.
Req. Certification/Licensure: None.
Employee Value Proposition
Prospect Medical Holdings, Inc., is guided by a diverse and highly experienced leadership core. This group maintains the vision that has made Prospect a needed difference-maker in the lives of so many patients today, and many executives contribute to our continued efforts. As a member of our highly effective team of professionals, benefit eligible positions will receive:
- Company 401K
- Medical, dental, vision insurance
- Paid time-off
- Life insurance
How to Apply
To apply for this role, or search our other openings, please visit http://pmh.com/careers/ and click on a location to begin your journey to a new career with us!
We are an Equal Opportunity/ Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources.
EEOC is the Law: https://www.eeoc.gov/
Keywords: Utilization Review, UR, Case Management, CM, Acute Care Hospital