Clinic Utilization Review Specialist

Sidney Regional Medical Center•Sidney, NE

About The Position

Join our caring community at Sidney Regional Medical Center in Sidney, Nebraska! We are currently pursuing a non-licensed, full-time Clinic Utilization Review Specialist to join our Case Management team. At SRMC, our patients are our number one priority. We aim to provide extraordinary care every single day by ensuring that our patients’ well-being comes first, but amazing patient care starts with YOU. Your positivity and knowledge will greatly improve their experience! Loan Repayment: SRMC is a qualifying employer for the federal Public Service Loan Forgiveness (PSLF) program! We provide employees with free assistance navigating the PSLF program to submit their federal student loans for forgiveness. Why Us: · Panhandle Hospitality: Bring your warmth and kindness to our patients with a smile. · Close-Knit Team: Small community, big heart – where every team member makes a difference. · Meaningful Impact: Your dedication transforms lives and creates a supportive, caring environment. This individual will be responsible for the completion of medical prior authorizations for the facility, helping nursing staff with medical necessity, obtaining patient health information required for admissions, and obtaining proper authorizations as required by SRMC policy.

Requirements

High school graduate or GED.

Nice To Haves

Prefer clerical/medical and prior authorization experience.

Responsibilities

Provide excellent customer service.
Ensure that prior authorization requests are completed in a timely fashion to meet contractual requirements.
Ensure all reviews are conducted using nationally recognized and evidence-based standards.
Analyze insurance, governmental, and accrediting agency standards to determine criteria concerning medical justifications and treatment or procedures.
Knowledgeable of criteria for Medicare, Medicaid, and private insurance coverage.
Efficiently navigate insurance provider portals.
Collaborate with nurses, physicians, and ancillary staff to ensure all information and documentation is obtained to support authorization, level of care, and/or medical appropriateness.
Act as a resource to other departments, leveraging expertise relative to the authorization and medical necessity process.
Respond to common inquiries or complaints from patients or regulatory agencies and address them, forwarding them to the appropriate person when necessary.
Retrieve patient data in Electronic Medical Record.
Perform and maintain accurate documentation.
Communicate effectively with medical providers, nursing staff, rehab team, and social workers to meet the needs of the patient.
Assist director with identifying and completing process improvements for the facility that involves authorization activity.
Perform non-clinical Case Manager duties in Acute Care when needed.
Assist director when appropriate in research to reduce denials and improve reimbursement.
Other duties as assigned by management.