Utilization management assistant

Job Details

Summary
Works under the direction of the U.M. Manager to provide assistance with utilization review process including communicating clinical information/reviews to third party and governmental payers to ensure certification/approval of inpatient hospital services for the Medical Assistance patient population.

Job Description

Summary
Works under the direction of the U.M. Manager to provide assistance with utilization review process including communicating clinical information/reviews to third party and governmental payers to ensure certification/approval of inpatient hospital services for the Medical Assistance patient population.

Job Duties

• Interacts with co-workers, visitors, and other staff consistent with the values of Jefferson.(Do not delete, move or over-write this statement)
• Negotiates with payer (DPW) and other commercial payers to obtain authorization for appropriate level of care and length of stay.
• Responsible for meeting insurer timeframes regarding review of clinical information.
• Provides prompt feedback regarding denials and other payer determinations to the U.M. Manager.
• Coordinates appeal requests (telecom and other payers) with payers as directed by U.M. Manager.
• Interacts with co-workers and other staff consistent with the core values of the hospital.

Minimum Qualifications

• Computer literate, strong knowledge of medical terminology required.
• Knowledge of the techniques and the ability to work with a variety of individuals and groups in a constructive and collaborative manner.
• Communication techniques
• Ability to manage multiple concurrent objectives, projects, groups, or activities, making effective judgments as to prioritizing and time allocation
• Answers phones in a prompt and courteous manner directing calls and messages to the appropriate individual.
• Collaborates with Business Services to ensure accuracy of patient information. Communicates updated information to all appropriate parties in a timely manner.
• Communicates with the Supervisor/UMA colleagues when experiencing capacity to work on additional cases or need assistance.
• Communicates with third party payers for verification of insurance benefits/coverage on assigned patients.
• Communicates timely, relevant and accurate information to the U.M. Manager and U.M. RNs.
• Documents all approvals, denials, updates and other pertinent information in relevant applications.
• Effectively communicates all forms of clinical information to all payers.
• Ensures payer and customer satisfaction through effective communication and positive customer service skills at all times.
• Ensures utilization management information is submitted to relevant third party payers within the defined timeframes.
• Identifies and communicates cases requiring clinical review for the U.M. Manager, including timeframes for submission of reviews.
• Keeps supervisor informed of changes in workload.
• Keeps supervisor informed of Third Party Payer patterns and trends.
• Maintains confidentiality of patient information.
• Maintains routine and frequent communication with U.M. Manager/U.M. RN on the status of their referral requests.
• Notifies U.M. Manager and/or UM Nurses or Case Manager of the need for utilization information.
• Obtains authorization for appropriate level of care and length of stay from third party payers.
• On a daily basis, organizes and creates a priority work list to ensure clinical reviews are completed timely. Works with U.M. Manager to prioritize competing requests.
• Participates in daily sessions with the U.M. Manager to ensure key issues are prioritized and addressed that day.
• Proactively communicates any change in payer information to Supervisor and/or Manager and Seamless Access and documents changes appropriately.
• Provides updates to the U.M. Manager or UR Nurse if there are “pending” approvals and additional clinical information is needed for the third party payer to make a determination.
• Provides prompt feedback regarding adverse determinations and denials to appropriate staff.
• Responsible for meeting insurer timeframes regarding utilization management information.
• Scans approvals and denials into the electronic medical record.

Physical Demands
Lift and carry 40-50 lbs. Examples: Push/pull patients on bed, stretcher (requires 29 lbs. push force), lateral transfers up to 50 lbs. of the patient's weight. Frequent to continuous standing/walking. Patient transporters can walk 8-10 miles per shift. *Patient care providers may be required to perform activities specific to their role including kneeling, ben