Utilization Review Authorization Coord - REMOTE

The Utilization Review Authorization Coordinator will work with RN Case Managers and other facility staff to coordinate the appropriate information and actions necessary to ensure proper authorizations are obtained for care of patients. Identify denial patterns and works with DCM and Care Management Team to positively impact outcomes.

KEY RESPONSIBILITIES:

• The Utilization Review staff assumes primary responsibility of communicating with payors to obtain authorization.
• Attention to detail regarding documentation and follow-up to ensure process completed timely.
• Effectively interact with all levels of the organization and maintain cooperative relations with internal and external customers.
• Coordinates with UR RN to send the clinical information to payor on specific accounts.
• Document authorization numbers, concurrent denial, attempts to overturn concurrent denials and coordinate Peer-to-Peer communication as needed for all patient hospital stays.
• Follow-up communication with payors to ensure authorization obtained for patient hospitalization.
• Communicate appropriately with Care Manager and Social Worker regarding authorization status and payor requests.

REQUIRED KNOWLEDGE & SKILLS:

• Good organizational skills.
• Ability to assist in development and process improvement in obtaining payor authorization and concurrent denial appeals.
• Manages time effectively, sets priorities, and consistently meets deadlines.
• Excellent verbal and written communication skills.
• Ability to effectively interact with insurance companies.
• Demonstrates initiative and pro-active approach to problem resolution.
• Performs well independently and on a team.
• Assumes accountability for demonstrating behaviors consistent with the customer service policy.
• Works competently with computer based charting and other clinical and non-clinical software programs. Readily adapts to change.
• Understands Medicare and Medicaid coverage details.
• Operates office equipment efficiently.
• Critical thinking skills required.
• Utilizes independent judgment and discretion in the UR Coordinator role.
• Understand CMI, patient status, InterQual Criteria, Milliman Criteria, and Transfer DRGs.

EDUCATION/EXPERIENCE/LICENSURE/TECHNICAL/OTHER:

1. Education: Minimum High School graduate or GED equivalent.
2. Experience (Type & Length): Two 2 - 4 years’ experience in healthcare preferred.
3. Certification/Licensure: None.
4. Software/Hardware: Basic computer knowledge required, i.e. Word, Excel, Microsoft Office
5. Other: Understanding of the health care delivery setting. Ability to read and communicate effectively in English required, ability to communicate in additional languages preferred.