The Utilization Management Coordinator l might carry out duties in a number of of the next areas: Prior Authorization Unit, Hospital Notification Unit, Concurrent Evaluate Unit, Medical Assessment Unit or Medicare Outreach Staff.
The Utilization Management Coordinator l helps and coordinates consumption actions in Medical Management.
Important Duties & Obligations
Demonstrates common, dependable and predictable attendance.
All Models:
Precisely and successfully applies insurance policies, profit and eligibility insurance policies, procedures and requirements; requesting help of supervisor or appropriately licensed well being skilled when essential.
Precisely paperwork all actions as per coverage together with entry into automated methods.
Meets or exceeds established efficiency objectives together with however not restricted to service, high quality, productiveness and switch-round time.
Professionally interacts with clients, appearing as a liaison between the beneficiary, supplier, facility and Health Internet.
Maintains confidentiality of all PHI in compliance with state and federal regulation and Health Internet Coverage.
Reviews suspected fraud and abuse as per firm coverage.
Performs required clerical help duties.
Performs different duties as assigned
Prior Authorization Unit (PCU):
Solutions in-coming calls and responds appropriately to telephone and faxed prior authorization requests.
Authorizes particularly designated providers, based mostly on firm coverage that don’t require medical necessity evaluate.
Requests medical data per process.
Refers requests and notifications to appropriately licensed well being skilled for evaluation.
Generates letters or approval of authorizations.
Hospital Notification Unit (HNU):
Solutions in-coming requires hospital inpatient notification.
Enters and updates Inpatient notifications into Medical Management and Vendor methods as applicable.
Performs outbound calls to Main Supplier Teams (PPGs) and Amenities for verification and /or further info.
Routes Instances to Concurrent Assessment UMC or RN as applicable.
Concurrent Evaluate Unit (CCR):
Offers administrative help to licensed well being professionals to collect and enter pertinent info, supporting Medical Management features for the Medical Concurrent Evaluation Workforce. Interacts with contracted suppliers and amenities to analysis points, gather required info and/or talk necessities or approval determinations.
Performs outbound calls to PPG and Faclities to acquire discharge tendencies for one line of enterprise.
Creates and updates Discharge Tendencies for Concurrent Evaluate admissions.
Medical Evaluation Unit (MRU):
Performs non-medical medical declare evaluation.
References CPT codes, ICD-9 codes and medical terminology
Forwards medical or medical necessity assessment to licensed well being professionals as applicable.
Performs outbound calls to Main Supplier Teams (PPGs) for authorization verification.
Enters and paperwork prior authorizations into applicable claims processing system based mostly on info offered by PPG.
Responds to Service Types (SF) for claims processing
Medicare Outreach Staff (MOT):
Performs outbound outreach calls to members and suppliers in help of Medicare program and QI initiatives resembling RAF, Star Scores, and so on.
Solutions in-coming calls associated to outreach actions.
Cross trains to help different Medical Management Models – PCU, HNU, CCR and MRU.
Schooling
Excessive Faculty diploma or GED required
Certification/Licensure Required
N/A
Authorities Clearance & US Citizenship Requirement
N/A
Expertise Required
Six months knowledge entry expertise.
Expertise in a well being care, customer support or a managed care setting most popular.
Information, Expertise & Talents
Pc expertise and dealing information of Microsoft merchandise, and PC- based mostly software program
Capability to study new software program purposes
Proficient and correct keyboarding expertise
Wonderful verbal and written communication expertise
Skilled phone etiquette and expertise
Wonderful group expertise
Helps staff and builds efficient and trusting relationships
Working Circumstances
The next part describes the overall bodily necessities for this place. Please word that ‘fixed’ refers to greater than 81% of time; ‘vital‘ refers to 40-80%; and ‘average’ refers to 20-40% of the time.
Operates private computer systems, printers, facsimile, telephones, copy machines and different generally used workplace equipment/gear.
Uncovered to confidential info and anticipated to take care of confidentiality always; should adhere to HIPAA guidelines and laws.
Could also be required to work outdoors of usually scheduled hours as mandated by the shopper, undertaking and/or workload (e.g. evenings, weekends, and/or holidays).
Could also be required to take care of established work tempo, meet deadlines; might have final minute pressing requests.
Bodily exercise might embrace: twisting, reaching, kneeling, bending, stooping, squatting, crawling, greedy, grabbing, pushing, pulling, repetitive movement, climbing, and so on.
Required to have visible acuity to find out the accuracy, neatness, and thoroughness of the work assigned.
Required to have listening to potential to obtain detailed info by way of oral communication.
Required to have talking means to precise or change concepts.
Fixed focus could also be required on numerous topics by listening, studying and considering clearly.
Interplay with others could also be required. Might have to pay attention, assume, and converse with a view to work together with others. Enterprise interactions and conduct between coworkers and/or exterior clients are required. This will likely require face-to-face or phone interactions.
Considering at work might embrace listening, studying, analyzing, evaluating, and the power to interpret what’s seen and/or heard, or to hyperlink info from one challenge to the subsequent.
Fixed pc utilization together with typing and/or eye pressure.
Fixed repetitive arm, wrist, hand and finger motions — making repetitive actions (e.g. key boarding, submitting, knowledge entry).
Fixed telephone utilization; headsets could also be required.
Vital period of time spent working in a loud workplace setting with frequent interruptions/distractions.
Fixed sedentary work (desk sure or seated).
Fixed studying is required by way of pc display and/or sure printed supplies.
Disclaimer
DISCLAIMER: The above statements are meant to explain the overall nature and degree of labor being carried out by people assigned to this job. They don’t seem to be meant to be construed as an exhaustive listing of duties, duties and expertise required of personnel so categorised.
Location:
Health Internet and its subsidiaries are an Equal Alternative/Affirmative Motion Employer – Minorities/Females/Veterans/Incapacity
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