Utilization Management & Appeals Specialist

NorthShore University HealthSystem; Warrenville (IL); On-site; USD 31,000 - 46,000; Full time

Benefits offered by this job

Premium pay

Incentive pay

Tuition Reimbursement

Free Parking

Paid Time Off

Health plan options

Job summary

NorthShore University HealthSystem in Warrenville, IL, is seeking an Utilization Management Clinical Assistant to support the Utilization Review workflow. You will conduct precerts, discharge reviews, and insurance follow-up calls to help manage patient care and approvals.

The role requires a Bachelor's degree, familiarity with behavioral health, and experience with insurance appeals. Proficiency in Microsoft Office and familiarity with DSM-IVR criteria are preferred.

Qualifications

• Bachelor's degree required.
• Proficiency in Microsoft Office products.
• Familiarity with behavioral health field, terminology and levels of care.
• Knowledge of DSM IVR (Diagnostic and Statistical Manual of Mental Disorders) diagnostic criteria.
• Experience completing and submitting insurance appeals.
• Knowledge of insurance benefits, authorization requirements, and payer appeal processes.

Responsibilities

• Demonstrates the knowledge and skills necessary to provide care appropriate to the age of patients served.
• Understands where to locate information in the chart or clinic documentation.
• Completes discharge reviews.
• Checks charges, attendance functionality, and notes to check outpatient days attended.
• Supports authorization processes by completing authorization by any necessary means.
• Identifies cases for the Financial Appeals Log and Clinical Appeals Log.
• Assists in coordinating appeal efforts prior to discharge.
• Reviews Appeals Log and writes reconsideration letters to insurers.
• Updates Appeals Log statistics and prepares UM Committee data.
• Makes follow-up calls to insurance companies on status of pending appeals.

Skills

Behavioral health knowledge

Insurance appeals experience

Payer appeal processes understanding

Education

Bachelor's Degree Required

Tools

Microsoft Office

Insurance systems (billing portal)

Job description

NorthShore University HealthSystem in Warrenville, IL, is seeking an Utilization Management Clinical Assistant to support the Utilization Review workflow. You will conduct precerts, discharge reviews, and insurance follow-up calls to help manage patient care and approvals.

The role requires a Bachelor's degree, familiarity with behavioral health, and experience with insurance appeals. Proficiency in Microsoft Office and familiarity with DSM-IVR criteria are preferred.