Utilization Management Coordinator (Home-Based) - Prior Authorization

Good Samaritan Society; South Dakota; Remote; USD 60,000 - 80,000; Full time

Job summary

An established industry player in healthcare is seeking a dedicated professional to enhance patient care through effective resource management and clinical documentation. This role offers the opportunity to work remotely while ensuring compliance with healthcare regulations and insurance requirements. You will collaborate with various departments to guarantee accurate patient information and authorization processes. With a focus on quality care, you will play a vital role in supporting both patients and healthcare providers, making a significant impact in the lives of those you serve. Join a team that values your expertise and offers a comprehensive benefits package to support your well-being.

Benefits

Health Insurance

Dental Insurance

Vision Insurance

401(k) Retirement Plan

Generous Time Off Package

Qualifications

• Seven years of relevant experience in healthcare or clinical settings.
• Current LPN license or RHIT certification required.

Responsibilities

• Monitor resource utilization and quality of care for patients.
• Input collected data into systems for insurance communication.

Skills

Interpersonal Skills

Communication Skills

Data Management

Clinical Experience

Education

Licensed Practical Nurse (LPN)

Registered Health Information Technician (RHIT)

Coding Certifications

Tools

Microsoft Applications

Job description

Sanford Health

Sanford Health is one of the largest and fastest-growing not-for-profit health systems in the United States. We're proud to offer many development and advancement opportunities to our nearly 50,000 members of the Sanford Family who are dedicated to the work of health and healing across our broad footprint.

Facility: Remote SD (Central Time)
Location: Remote, SD
Address:
Shift: Day
Job Schedule: Full time
Weekly Hours: 40.00
Salary Range: $21.50 - $28.00

Opportunity to work remote

Job Summary

Monitors the utilization of resources, risk management and quality of care for patients in accordance to established guidelines and criteria for designated setting and status. Collection of clinical information necessary to initiate commercial payor authorization. Obtain and maintain appropriate documentation concerning services in accordance to reimbursement agency guidelines. Consult with interdepartmental departments and staff to assure all relevant information regarding patient status and diagnosis are accurately reported. Provide information via multiple sources of technology applications to insurance companies and contracted vendors to assure authorization for patients. May participate in providing assistance in financial aid and/or counseling if applicable.

Accurately recognizes coding principle diagnosis and principle procedures including complicating/comorbid diagnoses for accurate diagnosis-related group (DRG) assignment during hospitalization. Monitors patient hospitalization to ensure prospective payment limit is not exceeded without due notice to the attending physician. May also need to notify physician and patient of authorization denials. Inputs collected data into computer system for insurance communication, DRG grouping, data abstraction for monitoring and evaluation, and when applicable, Medicare National and Local Coverage Determinations (NCD/LCD), and Joint Commission (TJC) required functions and credentialing. Assists medical records coding personnel as needed to correctly identify diagnoses and procedures, and obtains physician documentation as needed. Monitors patient hospitalization to ascertain medical necessity and appropriateness. Assists with retrospective review of specified charts as required.

Ability to interact on an interpersonal basis with both providers and nursing staff. Demonstrates proficiency with computers, Microsoft applications, and additional designated technology within the department. Will perform multiple administrative duties including accurate record keeping and electronic data management when needed. Ability to work with growth and development needs of pediatric to geriatric populations.

Qualifications

Appropriate education level required in accordance with licensure.

Seven years of relevant experience, superior communication and interpersonal skills. Minimum one year healthcare or clinical experience required.

Specific background or experience in healthcare reimbursement, insurance industry, and/or authorization experience would be critical to the success in this role and preferred.

Currently holds an unencumbered Licensed Practical Nurse (LPN) license with State Nursing board and/or possess multi-state licensure privileges, or Registered Health Information Technician (RHIT) required. Additionally, pharmacy technician or coding certifications also acceptable, i.e. Certified Coding Specialist (CCS), Certified Coding Specialist - Physician based (CCS-P), Certified Professional Coder (CPC), Certified Professional Coder - Hospital (CPC-H), Certified Outpatient Coder (COC), or Certified Ambulance Coder (CAC).

Obtains and subsequently maintains required department specific competencies and certifications.

Sanford Health offers an attractive benefits package for qualifying full-time and part-time employees. Depending on eligibility, a variety of benefits include health insurance, dental insurance, vision insurance, life insurance, a 401(k) retirement plan, work/life balance benefits, and a generous time off package to maintain a healthy home-work balance. For more information about Total Rewards, visit https://sanfordcareers.com/benefits .

Sanford is an EEO/AA Employer M/F/Disability/Vet. If you are an individual with a disability and would like to request an accommodation for help with your online application, please call 1-877-673-0854 or send an email to [e-mail] .

Sanford Health has a Drug Free Workplace Policy. An accepted offer will require a drug screen and pre-employment background screening as a condition of employment.

Req Number: R-0222596
Job Function: Care Coordination