Insurance Specialist - Sunnyview Hospital - FT Days
About The Position
Position Summary: The Insurance Specialist under general supervision, supports the administrative requirements for Utilization Management and works collaboratively with Utilization Management/Concurrent Review Nurse, physicians, staff and other health care professionals. Interacts with internal and external providers to review and monitor members’ utilization of health care services with the goal of maintaining high-quality cost-effective care. Works collaboratively with staff to obtain information from clinical reviews and medical records in order to provide the appropriate communication for authorization of medical services and procedures. Collaborates on system-wide quality improvement/performance improvement. Initiates and ensures authorizations for all admissions • Extracts meaningful data from the medical record of identified patients • Processes electronic communications within identified process standards • Actively participates in quality activities by communicating and coordinating with the care management team in the development of tools for optimal consumer outcomes and report findings • Upon identification of possible concurrent denials, forwards information to the appropriate Utilization Management/Concurrent Review Nurse within identified process standards • Reviews any service denials and gathers necessary supporting documentation from chart audits and follows up according to procedures • Provides external notifications of discharges and external post-acute transfers • Clarifies health plan medical benefits, policies and procedures for members, physicians, medical office staff, contract providers, and outside agencies • Actively participates in the discussion and notification processes that result from the clinical utilization reviews with the facilities Per Diem- Insurance Specialist to assist with authorizations for Substance abuse and Mental Health Service lines Position Highlights: Quality of Life: Where career opportunities and quality of life converge. Advancement: Strong orientation program, generous tuition allowance and career development Work/Life: Positions and shifts to accommodate all schedules.
Requirements
- High School Diploma / Associates degree preferred in a healthcare related field.
- One year experience in a healthcare environment utilizing medical terminology or have completed a college level course in medical terminology.
- One year of case management or utilization review/billing or coding experience.
- One year of experience in coding/medical records/billing or healthcare related field
- One year of case management or utilization review, billing, or coding experience
- Please be aware for the safety and security of our colleagues and patients all new employees are required to undergo and pass all applicable state and federally mandated pre-employment screening requirements including:
Responsibilities
- Initiates and ensures authorizations for all admissions
- Extracts meaningful data from the medical record of identified patients
- Processes electronic communications within identified process standards
- Actively participates in quality activities by communicating and coordinating with the care management team in the development of tools for optimal consumer outcomes and report findings
- Upon identification of possible concurrent denials, forwards information to the appropriate Utilization Management/Concurrent Review Nurse within identified process standards
- Reviews any service denials and gathers necessary supporting documentation from chart audits and follows up according to procedures
- Provides external notifications of discharges and external post-acute transfers
- Clarifies health plan medical benefits, policies and procedures for members, physicians, medical office staff, contract providers, and outside agencies
- Actively participates in the discussion and notification processes that result from the clinical utilization reviews with the facilities
Benefits
- Quality of Life: Where career opportunities and quality of life converge.
- Advancement: Strong orientation program, generous tuition allowance and career development
- Work/Life: Positions and shifts to accommodate all schedules.
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
High school or GED
