Utilization Review Associate

Overview

Receives, documents, investigates, refers, and coordinates grievances and appeals. Initiates case files for each grievance and ensures compliance with organizational and regulatory requirements. A significant portion of the day will be devoted to clerical functions related to medical records in various locations in the hospital.  This role is ONSITE at Hampstead Hospital. 

Responsibilities

Assists others in the appeals process. Communicates to insurers. Documents activity and provides information upon request.

Maintains ongoing monitoring of Denial Management system and takes action based on status of denial. Enters all paper denials into the Denial System.

Coordinates with Revenue Management and Patient Access staff around medical necessity denials that may overlap between the various departments.

Visits Medicare patients and Medicare Advantage patients daily. Communicates Medicare Important Notices of Patient Discharge Rights.

Orders medical records and faxes clinical information to insurers.

Collaborates with outside contracted agencies performing appeals.

Develops and provides reports to demonstrate outcomes of denials work and effectiveness of appeal process.

Manages all incoming mail and correspondence to the Appeals office.

Reviews and confirms monthly status reports.

Collects and coordinates data collection to provide data base reports regarding patient notices delivered.

Communicates with appropriate insurance company contact to provide necessary information to avoid a denial.

Performs other duties as required or assigned.

Qualifications

• Associate’s degree with 1 year of secretarial or administrative assistant experience in a medical setting required.
• Extensive experience with word processing, spreadsheets, and data processing required.
• The ability to function effectively and independently in a fast paced environment.
• Excellent interpersonal and communication skills required.

Required Licensure/Certifications

• None