Utilization Review Specialist - Full Time, Days (Bellflower) - 10506

NOR Healthcare Systems; Bellflower (CA); On-site; USD 32,000 - 41,000; Full time

Job summary

NOR Healthcare Systems Corp. is seeking an Utilization Review Specialist to support the Case Management Department under the Director/Manager.

This role interfaces with payors and providers to obtain authorizations, medical records, and necessary information, ensures timely submissions, and aids in coordinating daily operations. Responsibilities include conducting reviews, reducing denials with centralized processes, assisting with schedule coordination, and performing clerical tasks to keep the

Qualifications

• 2 years works experience
• Must demonstrate customer service skills
• Excellent written and verbal communication skills
• Ability to multitask and maintain a workload pace

Responsibilities

• Interfaces with payors and providers requesting authorizations, medical records, and other information.
• Completes payor and provider request for missing or additional documentation.
• Logs all authorization requests to ensure same-day submission.
• Forwards questions and authorizations to Director/Manager of Case Management.
• Performs basic reception functions to ensure smooth office operations.
• Types memos and documents, uses computer programs, and collects data into systems.
• Clears providers prior to patient access and ensures privacy guidelines are followed.
• Maintains audits for timely completion of Utilization Reviews and retroactive reviews.
• Cross references data for PI/Quality indicators and prepares presentations.

Job description

Position Summary

Under the direction of the Director/Manager of Case Management, the Utilization Review Specialist directs all back-office functions of the Case Management Department. Interfaces with all payors/providers requesting authorizations, medical records, and other specific information. Confirms completeness of reviews to payors. Redirects denials to centralized department. Assists the Lead Case Manager with coordinating schedules and assignments of Case Management Team. Provides clerical functions to the Case Management Department, ensuring smooth office operations.

Required Qualifications

• Knowledge of utilization management
• 2 years works experience
• Must demonstrate customer service skills appropriate to the job
• Computer literacy and proficiency
• Excellent written and verbal communication skills
• Ability to establish and maintain effective working relationships within the organization
• Ability to multitask and maintain a work pace appropriate to workload

Physical Requirements

These are requirements normally expected to perform regular job duties. Reasonable accommodations may be made in compliance with the Americans with Disabilities Act of 1990, and applicable, state and local law, to enable individuals with disabilities to perform the essential functions. Incumbent must be able to successfully perform all of the essential functions of the job with or without reasonable accommodation.

• Standing - Frequently
• Walking - Frequently
• Sitting - Frequently
• Reaching with Hands and Arms - Occasionally
• Climb or Balance - Occasionally
• Stooping, Kneeling, Crouching, or Crawling - Occasionally
• Talking - Constantly
• Hearing - Constantly
• Seeing - Constantly
• Performing repetitive motions with arms or hands - Occasionally
• Lifting, carrying, pushing or pulling up to 10 lbs - Occasionally
• Lifting, carrying, pushing or pulling up to 25 lbs - Occasionally
• Lifting, carrying, pushing or pulling up to 50 lbs - Occasionally
• Lifting, carrying, pushing, or pulling greater than 50 lbs - None
• Driving - Occasionally

Essential Job Functions / Major Areas of Responsibility

The essential functions below are not intended to be an exhaustive list of all duties that may be assigned to this position, nor does it restrict the duties which may be assigned to this position if such duties reasonably relate to the position.

• Interfaces with all payors and providers requesting authorizations, medical records, and other specific information. Completes payor and provider request for missing or additional documentation. Logs all authorization requests to ensure that they are submitted the same day as requested. Forwards all managed care/payor questions, correspondences and authorizations to Director/Manager of Case Management (or designee). Ensures that all requests are handled appropriately and in a timely manner.
• Performs basic reception functions to ensure smooth office operations, including answering incoming calls, maintaining an accurate filing system, ensuring office supplies stocked to appropriate levels and office equipment serviced, copying forms and documents, etc. Types memos and other case management documents as assigned. Effectively uses computer programs. Accurately collects and documents all necessary and required information and activities into the appropriate computer systems.
• Clears all providers, such as home health, LTACH, SNF, board and care, prior to providing patient access. Directs providers where they need to go and ensures they get there in a timely manner. Ensures that all patient privacy guidelines/laws are followed.
• Maintains audits for timely completion of Utilization Reviews. Completes audits for retroactive reviews and provides same day summary to Director of Case Management. Ensures that all reviews are completed and received by the payor in a timely manner.
• Maintains status and oversees required performance improvement data/documents for current PI/Quality indicators. Cross references multiple sources of data, ensuring that information is in appropriate place in patient medical records.
• Accurately collects data and organizes graphs, PowerPoints, or needed presentation materials under the direction of the Leader of the Department and/or UR Committee members. Completes all assigned Performance Improvement tasks in a timely and accurate manner. Accurately collects data and organizes graphs, PowerPoints, or needed presentation materials under the direction of the Leader of the Department and/or UR Committee members.

Pay Rate: Min - $23.20 l Max - $30.10

Job Listing ID:1897672