General Summary

Performs a variety of duties related to pre-certification requirements for Medicare, Medical Assistance and third-party payers. Ensures timely notification and communication of pertinent clinical data to support admission, clinical condition, and continued stay. Assists with data collection, analysis and reporting.

Shift

Full Time, 8:00-4:30p

Duties and Responsibilities

Essential Functions:

Reviews assigned cases for preauthorization and coordinates authorization and certification. Performs concurrent review of cases to obtain continued stay authorization. Provides notification of discharge date and discharge destination to payer. Works closely with and prepares information for outside review agencies. Assists with the collection and analysis of utilization patterns and denied cases. Supports the Utilization Management Nurse with case research and analysis. Works with medical and professional staff on a case-by-case basis to obtain appropriate clinical documentation for review as well as coding activities and DRG assignments. Liaisons between third party payors, physician advisor team and the care team regarding questions related to authorization status and/or contractual guidelines. Refers third party payer denials and downgrades to the physician advisor team and follow through with the recommendations. Provides feedback to payer contracting regarding payer actions that cause barriers to the utilization review process. Maintains up to date tip sheet on assigned payer/payers utilization review process.

Common Expectations:

Maintains established policies and procedures, objectives, quality assessment and safety standards. Participates in educational programs and inservice meetings. Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation.

Qualifications

Minimum Education:

High School Diploma or GED Required Associates Degree Preferred

Work Experience:

2 years Utilization Management. Required

Knowledge, Skills, and Abilities:

Basic computer skills.

Benefits Offered:

Comprehensive health benefits Flexible spending and health savings accounts Retirement savings plan Paid time off (PTO) Short-term disability Education assistance Financial education and support, including DailyPay Wellness and Wellbeing programs Caregiver support via Wellthy Childcare referral service via Wellthy You’re unique and you belong here.

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