Utilization Review Technician I

Overview

Prime Healthcare is an award-winning health system headquartered in Ontario, California. Prime Healthcare operates 45 hospitals and has more than 300 outpatient locations in 14 states, providing over 2.6 million patient visits annually. It is one of the nation’s leading health systems with nearly 50,000 employees and physicians. Fourteen of the hospitals are members of the Prime Healthcare Foundation, a 501(c)(3) not-for-profit public charity. Prime Healthcare is actively seeking new members to join our corporate team!

We are an equal employment opportunity employer. We prohibit discrimination and harassment based on race, color, sex, sexual orientation, gender identity, religion, national origin, age (per applicable law), disability, military status, genetic information, or any other protected category under federal, state, or local laws. Know Your Rights: https://www.eeoc.gov/sites/default/files/2022-10/EEOC_KnowYourRights_screen_reader_10_20.pdf

Privacy Notice for California Applicants: https://www.primehealthcare.com/wp-content/uploads/2024/04/Notice-at-Collection-and-Privacy-Policy-for-California-Job-Applicants.pdf

Responsibilities

The Utilization Review Technician coordinates the utilization review and appeals process as part of denial management initiatives. Responsibilities include managing phone calls, data entry, mailing/faxing appeals, and tracking data from insurance providers and health plans regarding authorizations, expedited reviews, and appeals. The technician documents and tracks all communication attempts and scans related correspondence into the EMR or tracking tools. They follow up on denials, working closely with the Corporate/Facility Utilization Review teams, Business Office, and Case Managers. The technician also maintains the integrity of government review audits (RAC, MAC, CERT, ADR, Pre/Post Probes, QIO/Medicaid) and other payer audits. Additionally, they support department needs such as Release of Information, discharge coordination, and other duties as assigned.

Qualifications

Required qualifications:

• High School Diploma or Equivalent
• Proficiency in Microsoft Office
• Good communication skills

Preferred qualifications:

• At least one year of denials management experience in an acute care setting (highly preferred)
• Completion of a medical terminology course (preferred)
• Knowledge of HIPAA regulations (preferred)

Prime Healthcare offers competitive compensation and a comprehensive benefits package, including paid time off, a 401(k) retirement plan, medical, dental, and vision coverage, tuition reimbursement, and other voluntary benefits. The estimated total compensation range for this role is $21.00 to $30.51 per hour, depending on factors such as experience, education, and credentials.