Utilization Review Tech I in Ontario, CA at Prime Healthcare

Date Posted: 9/7/2019

Job Snapshot

Job Description



Overview

The Utilization review tech essentially works to coordinate the utilization review and appeals process as part of the denial management initiatives. Utilization review tech is responsible for coordinating phone calls, data entry and tracking data from various insurance providers and health plans regarding authorization, expedited reviews and appeals. Document and track all communication attempts with insurance providers and health plans. Utilization review tech will follow up on all denials while working closely with the Corporate/Facility Utilization review teams, Business Office and Case Managers. The Utilization review tech will also serve as the primary contact and coordinate the work to maintain integrity of tracking government review audits (RAC, MAC, CERT, ADR, Pre/Post Probes, QIO/Medicaid) and other payer audits as assigned. The Utilization review tech will further support the department needs for Release of Information, discharge coordination or other duties as assigned.

 

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Responsibilities


  • Maintain confidentially, protecting patient information at all times: minimum information necessary to those with right and need to know.

  • Coordinate all denials and appeal correspondence. Develop training and education for issues identified in RAC and authorization. Conducts oversight of all denial management functions. Follow all denials/ appeal activity to closure.

  • Maintains data base for tracking denials, reason, appeals, and outcome of appeals. Track status of all appeal activity using automated tracking system.

  • Reviews medical records and other documentation to prepare Appeals packages.

  • Communicate and coordinate with various individuals/distributions and assist with the management of the day to day activities related to Government Audit Reviews, denials and appeals. Open communication between Corporate Team and Administration/ CFO, Business Office/ Financial Services, Case Management/ Physician Advisor. for clinical Review, RACs/ CMS

  • All insurance correspondence received in the mail room, administration and CM dept. should be collected, reviewed and scanned to the EMR. Distribute the correspondence to the respective departments.

  • Responsible for the communication of all new policy's, memorandums and processes from department and/or governmental payers

  • for all review audits.

  • Maintain integrity of Denials/Appeals database and assist in financial and clinical reporting of activity. Invoice submitted record requests, if applicable.

  • Responsible for review/analyze audits and insurance denial letters that are received and the validity of findings of various audit contractors.

  • Performs other duties as assigned or required.


 

Qualifications

Qualifications:


  • High School Diploma or Equivalent.


Preferred Qualifications: 


  • Minimum one year denials management experience in acute care setting highly preferred.

  • Bachelor’s degree preferred.

  • Accurate alphabetic, numeric, and/or terminal-digit filing skills.

  • Excel skills highly preferred.

  • Knowledge of State and Federal regulatory requirements for medical staff documentation; preferred.

  • Computer data entry with 10-key, with accurate typing speed of 35 wpm; preferred.

  • Completion of a medical terminology course; preferred.


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.  EEO is the Law: http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf