Utilization Review Insurance Specialist
Full Time
Portsmouth, OH 45662
Posted
Job description
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GENERAL SUMMARYWorks under the supervision of the Manager of UR Case Management and Administrative Director of HIM. The UR Assistant’s primary job function is to assist the nurse case managers in reviews of patient records concurrently for observation status, continued stay, prior authorization and discharge. Organizes patient information by insurance type and need for review. Meets with patients to deliver required patient information as needed. Supports each Strategic Value by providing exceptional service. Performs other duties as assigned.
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QUALIFICATIONS
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Education:
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High School Diploma or successful completion of an equivalent High School Exam Required
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Licensure:
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None
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Experience:
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1 year of healthcare experience required
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Insurance knowledge preferred
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Precertification, insurance verification or prior authorization experience preferred
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Interpersonal Skills:
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Ability to develop positive interactions with patients, families, physicians, and staff in order to effectively care for patients.
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Essential Technical/Motor Skills:
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Must have ability to use hands for repetitive simple grasping when writing, using computer, answering phone, copying and related office duties.
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Must have the ability to input data, type, copy, speak clearly, answer the telephone, good eye/hand coordination.
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Must be able to multi-task
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Essential Physical Requirements:
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The physical demand level is light to medium. Occasionally may lift up to 15 pounds; stands and/or walks one to four hours per day; sits five to eight hours per day; occasional bending squatting, and reaching.
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Essential Mental Requirements:
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Has contact with the general public and customer when performing all aspects of the job. Requires the ability to cope with deadlines, adjust to irregular activity schedules, concentrates, documents, prepares, and evaluate case management processes.
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Essential Sensory Requirements:
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Good vision is required to reviewing diagnostic data, and completing required documentation. The ability to communicate clearly is required to maintain effective contact with physicians and a variety of hospital personnel.
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Exposure to Hazards:
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Works in good physical surroundings. Occasionally exposed to dust, odor, body fluids, toxic substances, unpleasant patient care activities, and infectious diseases. Frequently exposed to noise.
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Other:
N/A
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JOB SPECIFIC DUTIES AND PERFORMANCE EXPECTATIONS
- Assists the Nurse Case Manager in initial review of physician and nursing clinical documentation on potential or inpatient admissions.
- Gathers appropriate clinical documentation regarding medical necessity, reimbursement and compliance to begin process for assuring and providing nurse case manager and insurance companies with needed information.
- Performs utilization review functions for outside review agencies in accordance with contractual obligations.
- Assures surgical prior authorizations are completed on a daily basis.
- Provides reviews in a manner of insurance preference, including; Fax, email and telephone.
- Documents utilizing Meditech all interactions between contractual agencies and multidisciplinary team.
- Manages denials as needed.
- Assists inpatient precertification daily with verification and insurance corrections, assists with authorizations on admissions and covers inpatient precertification to fill scheduling needs as assigned.
- Performs other duties as assigned
The following is a summary of the major job duties of this job. Other duties may be performed, both major and minor, which are not mentioned below. Specific activities may change from time to time.
Location: Southern Ohio Medical Center · Utilization Review
Schedule: Full-Time, Days, 100% Remote
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