Utilization management assistant

Jefferson Health Plans

6d • $17 - $23

About The Position

Works under the direction of the U.M. Manager to provide assistance with utilization review process including communicating clinical information/reviews to third party and governmental payers to ensure certification/approval of inpatient hospital services for the Medical Assistance patient population.

Requirements

• Computer literate, strong knowledge of medical terminology required.
• Knowledge of the techniques and the ability to work with a variety of individuals and groups in a constructive and collaborative manner.
• Communication techniques
• Ability to manage multiple concurrent objectives, projects, groups, or activities, making effective judgments as to prioritizing and time allocation

Responsibilities

• Interacts with co-workers, visitors, and other staff consistent with the values of Jefferson.(Do not delete, move or over-write this statement)
• Negotiates with payer (DPW) and other commercial payers to obtain authorization for appropriate level of care and length of stay.
• Responsible for meeting insurer timeframes regarding review of clinical information.
• Provides prompt feedback regarding denials and other payer determinations to the U.M. Manager.
• Coordinates appeal requests (telecom and other payers) with payers as directed by U.M. Manager.
• Interacts with co-workers and other staff consistent with the core values of the hospital.
• Answers phones in a prompt and courteous manner directing calls and messages to the appropriate individual.
• Collaborates with Business Services to ensure accuracy of patient information.
• Communicates updated information to all appropriate parties in a timely manner.
• Communicates with the Supervisor/UMA colleagues when experiencing capacity to work on additional cases or need assistance.
• Communicates with third party payers for verification of insurance benefits/coverage on assigned patients.
• Communicates timely, relevant and accurate information to the U.M. Manager and U.M. RNs.
• Documents all approvals, denials, updates and other pertinent information in relevant applications.
• Effectively communicates all forms of clinical information to all payers.
• Ensures payer and customer satisfaction through effective communication and positive customer service skills at all times.
• Ensures utilization management information is submitted to relevant third party payers within the defined timeframes.
• Identifies and communicates cases requiring clinical review for the U.M. Manager, including timeframes for submission of reviews.
• Keeps supervisor informed of changes in workload.
• Keeps supervisor informed of Third Party Payer patterns and trends.
• Maintains confidentiality of patient information.
• Maintains routine and frequent communication with U.M. Manager/U.M. RN on the status of their referral requests.
• Notifies U.M. Manager and/or UM Nurses or Case Manager of the need for utilization information.
• Obtains authorization for appropriate level of care and length of stay from third party payers.
• On a daily basis, organizes and creates a priority work list to ensure clinical reviews are completed timely.
• Works with U.M. Manager to prioritize competing requests.
• Participates in daily sessions with the U.M. Manager to ensure key issues are prioritized and addressed that day.
• Proactively communicates any change in payer information to Supervisor and/or Manager and Seamless Access and documents changes appropriately.
• Provides updates to the U.M. Manager or UR Nurse if there are “pending” approvals and additional clinical information is needed for the third party payer to make a determination.
• Provides prompt feedback regarding adverse determinations and denials to appropriate staff.
• Responsible for meeting insurer timeframes regarding utilization management information.
• Scans approvals and denials into the electronic medical record.

Benefits

• Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts.
• Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service.
• All colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps), have access to medical (including prescription) insurance.

What This Job Offers

• Career Level: Entry Level
• Education Level: No Education Listed