Utilization Review Tech

SUMMARY

Under direction of the Utilization Review Technician Supervisor, the Utilization Review Technician coordinates with the Utilization Management Department while being responsible for coordinating phone calls, clinical requests, upkeeps data entry, organizes denials and mailing/faxing appeals, tracking data from various insurance providers and health plans regarding authorization and/or denials, expedite reviews and documentation to insurance providers. Monitors patient charts and records to provide to responsible parties and request for authorization for hospital admission. Reviews treatment plans and status of approvals from insurers. Collects and compiles data as required and according to applicable policies and regulations. Performs administrative duties for the Utilization Management Department, and directed in several aspects of duties. Position is non-RN/LVN.

REQUIREMENTS

• Ability to establish and maintain effective working relationships across the Health System 
• Ability to interpret and understand various medical insurance plans and make accurate determinations regarding coverage 
• Follow up with insurance companies regarding the status of outstanding claims and necessary steps for resolution 
• Answer and review pertinent insurance correspondence to ensure complete and accurate reimbursement for medical claims 
• Responsible for working  payer correspondence, edits and aged account receivable, and identifying and correcting billing errors 
• Pull daily reports utilizing Microsoft Excel and providing correct correspondence to payer 
• Research payer rules and regulations to maintain current payer knowledge 
• Comply with HIPAA and other compliance requirements to protect patient confidentiality 
• Manage data in internal and external databases with accuracy 
• Provide high-level administrative support and assistance to the Director and Supervisor or other assigned leadership staff 
• Perform clerical and administrative tasks including drafting letters, memos, invoices, reports, and other documents for senior staff
• Prepare patient charts for medical audits 

EDUCATION & EXPERIENCE REQUIREMENTS:

• High School Diploma 
• Healthcare experience strongly preferred

SKILLS & ABILITIES REQUIREMENTS:

• Excellent verbal and written communication skills
• Excellent organizational skills and attention to detail 
• Excellent time management skills with a proven ability to meet deadlines 
• Ability to function well in a high-paced and at times stressful environment 
• Extensive knowledge of office administration, clerical procedures, and recordkeeping systems 
• Able to type minimum of 50 words per minute 
• Knowledge of CMS, State Regulations, URAC and NCQA guidelines preferred.
• ICD-10 and CPT coding experience a plus
• Experienced computer skills with Microsoft Word, Microsoft Outlook, Excel and experience working in a health plan medical management documentation system a plus
• Extremely proficient with Microsoft Office Suite or similar software with the ability to learn new or updated software 
• Medical Terminology preferred

PHYSICAL REQUIREMENTS:

• Body Positions: Sitting and standing for prolonged periods.

• Body Movements: Arm and hand dexterity.

• Body Senses: Must have command of close and distant sight, color perception and hearing.

• Strength: Ability to lift and move up to 25-pounds.

Working Environment:

• Work in an office, where the climate is controlled.
• OSHA exposure category: II

1. Category I – Position includes tasks that involve exposure to Blood borne Pathogens.
2. Category II – Position includes tasks that do not have exposure to Bloodborne Pathogens, however employment may require unplanned Category I tasks.
3. Category III – Positions includes tasks that do not involve exposure to Bloodborne Pathogens.  This position would not be required to perform Category I tasks.