Utilization Review Professional-FT/Days

Location: 
SMMC-SMMC Hospital
Schedule: 
Full Time
Shift: 
Day Job
Job Listing: 
SAD003069
Case Management - Utilization
The Utilization Review Professional, uses decision trees, standard work and clinical expertise works to obtain authorizations for payment by timely management of cases not paid as expected for any number of reasons including but not limited to LOC authorizations, denials and billing disputes. The Utilization Review Professional analyzes charges, reimbursement and contract information to determines appropriate chart, telephonic and/or written justification and timely transmits the information, as well as, performs any needed follow up required to obtain the authorization.

Essential Job Outcomes & Functions

  • Completes assigned work queues daily by analyzing contracts, authorizations and MD orders and chart documentation using clinical expertise to determine appropriateness of authorizations/payments received.
  • Manages accounts in assigned work queues daily utilizing decision trees, standard work and clinical expertise to pursue authorizations for denials and billing disputes.
  • Analyzes charges, reimbursement and contract information to determine appropriate chart, telephonic and/or written justification
  • Reviews documentation in the billing system of activities and ensures that authorizations are complete and timely.
  • Performs any needed follow up required to obtain completed authorizations.
  • Duties performed meet standard work, department productivity and timeliness requirements.
  • Accepts full responsibility for personal behavior and contributes as a team member to complete tasks, resolve problems, and achieve goals. Follows through on commitments. Take responsibility for their actions.
  • Complies with regulatory requirements, applicable laws, and policies and procedures set forth by the organization and individual departments. Maintains all license and certification requirements.
Qualifications: 

Qualifications/Work Experience:

2 years experience as a case manager with strong utilization management skills, knowledge of MGG/Interqual Guidelines, clinical reviews, payor authorizations and payor management experience. 

Previous accountabilities of obtaining concurrent authorization for hospitalization and understanding of appeals and denials preferred.

Education/Licensure/Certification:

Health care license is required (i.e. LVN).  AA Degree Preferred.

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