Overview:
Responsible for the receiving and preparation of cases for the utilization review process. Often the first point of contact for providers, patients, and other healthcare professionals. Ensures all required patient, provider, and facility information is received and processed for utilization review. This process can include data entry, provider outreach for further clinical information, and facilitation of referrals to case management. Often tasked with clerical duties such as managing paperwork, handling data entry, engaging with providers and facilities over claims, and answering phones. Conducts nonclinical job functions on the utilization review team and is not required to interpret clinical information including non-certification of requests.
Responsibilities:
Essential Functions:
- Identify and prioritize tasks received from nurse Utilization Reviewers. Responsibilities may include but are not limited to: Assisting in faxing initial, concurrent or discharge reviews to insurance companies
- Documentation of information submitted/received by phone or fax from insurance companies into EHR
- Management of phone lines, faxing of clinical information
- Process incoming faxes, scanning of documents and other clerical duties as deemed necessary to assist with the facilitation of Utilization Management functions.
- Tasks will be performed with accuracy, correct format, grammar, punctuation and spelling.
- Communicate progression and completion of tasks to Utilization Review nurses.
- Communicate and document conversations with internal and external providers in EMR.
- Inform team members of denials and potential denials so appropriate action can be taken by Utilization Review nurse.
- Respond to insurance requests for clinical reviews and EHR notifications within time frame designated by contractual obligations.
- Contact Utilization Review nurse when reviews are not documented.
- Assist with ensuring length of stay has been authorized through monitoring of approved days. This is to be done by calling/faxing discharge dates, inputting approved length of stay into EHR.
- Generates and submits EHR reports specific to third party payers.
- Utilization Management Assistant is accountable for maintaining departmental productivity, quality metrics and completing assigned tasks in compliance with regulatory and departmental requirements.
- Must follow all HIPPA rules and regulations when providing PHI to internal and external providers. This includes but not limited to the verification of phone and fax numbers, confirmation of appropriate receipt and appropriate identification of person information is shared with.
- Maintains daily contact with Utilization Review Specialist, Denial Specialist Nurse, Utilization Management Team Leader, and Patient Access Services.
- Assist with documentation in various departmental databases. Audit, run and review reports relevant to Utilization Management as requested to ensure accuracy of information and gather statistics for reporting purposes.
- Other task and assignments as necessary.
Specific Duties and Responsibilities for Care Coordination
- Maintains current knowledge and understanding of value based programs to develop education programs for provider engagement and implementation.
- Collaborates with Operations and other applicable departments in developing action plans for values based program improvement.
- Utilizes various modern computer applications in creating, maintaining, and updating records, reports, charts, and files (i.e., Microsoft Office, Epic, Tableau, Provider Portals, etc.)
- Maintains, updates, and manages department filing system for consistency to include retrieving files, records, reports, and charts as directed.
- Assist in reviewing medical records and documents and abstract clinic data for HEDIS reporting, meet daily goals and upload information to payer portals.
- Documenting findings in applicable HEDIS databases, spreadsheets and prescribed cloud-based platforms.
- Obtain monthly payer rosters and organize in corresponding electronic files. Complete discharge data and coordinate patient outreach for follow up care.
- Attend and actively participate in department related training and meeting activities.
- Meet quarterly with Operations on value-based contract performance and provide recommendations for best practices.
- Meet monthly with health plans to discuss performance metrics based on the shared saving contracts/incentive programs.
- Work collaboratively with the Quality Assurance department on Incentive programs for each health plan.
- Develop Excel based models and spreadsheets that are well-documented to evaluate historical trends.
- Communicate effectively insurance carriers and internal departments to establish relationships.
- Work Collaboratively with all health plans and internal staff as well as support operational departments to improve population health performance and achieve quality incentives
Qualifications:
Education:
- Bachelors Degree preferred. High school diploma or G.E.D required or Medical Assistant Certification acceptable to meet diploma or G.E.D requirement.
Experience:
- 1 Year hospital and/or insurance industry experience
- Basic knowledge of medical terminology.
- Excellent time-management and multi-tasking skills.
- Comfortable with and be able to thrive in an ever-changing environment.
- Demonstrates a high degree of customer focus and attention to service.
- Strong computer skills.
- Basic proficiency with Microsoft Word and Excel.
- Must be approachable, polite and have an impeccable work ethic, supporting the company's culture.
- Excellent communication skills, both written and verbal.
Licensure:
- Valid Florida drivers license required.
Training:
- Knowledge of Microsoft applications required. Possesses an intimate knowledge of Microsoft Excel including creating spreadsheets and utilization of its applications and functions.
The Health Care District of Palm Beach County is proud to be an Equal Opportunity Employer and Drug Free Workplace. We embrace diversity and do not discriminate based on race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics.