Utilization Management Assistant

Sarah Bush Lincoln•Mattoon, IL

3d•$19 - $29

About The Position

Performs notifications to payors for inpatient, observation, and outpatient-in-a-bed elective and non-elective admissions to Sarah Bush Lincoln Health Center and verifies eligibility documented by the registration clerk. Notifications must be made within 24 hours of admission or, for admissions during a weekend or holiday, by the end of the first working day thereafter. Failure to notify payors may result in denial or delay of claim payment. Supports Utilization Review RNs with submission of clinical data to payors as required. The role manages a diverse workload in a rapidly changing regulatory environment, including post-discharge notification to patients about changes in patient status.

Requirements

Associate's degree or high school education (required).

Responsibilities

Assist the Utilization Review Committee and utilization management activities, including preparing Physician Advisor peer-to-peer appeals and denial appeal letters, and conducting other audit activities as requested.
Collaborate with registration clerks, coders, and other staff to ensure patient information is correct.
Work with the Utilization Review RN team to provide accurate, complete clinical information to obtain authorization for inpatient or observation status.
Complete short-stay work queue reviews within five business days or earlier as directed by the UM Director.
Maintain working knowledge of approved status determination criteria and regulatory and survey standards, including Medicare, Medicaid, and Joint Commission requirements.
Document information in patient charts and email pertinent information to appropriate departments.
Escalate utilization management issues to the Director, Physician Advisors, and Utilization Review RNs in a timely manner, and monitor issues through resolution.
Identify payors requiring notification of hospital admission status and notify payors of patient admissions.
Investigate disputed medical claims.
Manage Medicare Part B notices to Medicare patients by certified mail.
Notify appropriate departments and staff of pertinent issues, including heart catheterizations, audit findings, Behavioral Health requests, and EQ notices.
Obtain diagnosis codes and confirm eligibility.
Document concise clinical pertinence throughout the EMR.
Request diagnosis and procedure codes from the Coding department for patients on the daily admission list and categorize them according to payor notification requirements.
Respond to telephone and written inquiries from clients, providers, payors, regulatory agencies, and departments across the healthcare system, and communicate information to appropriate staff promptly and efficiently.
Ensure appropriate data is tracked, evaluated, and reported.
Scan pertinent hard copies of approvals and denials into the EMR and document them.
Facilitate consistent and accurate patient status determination by Utilization Review RNs and others for appropriate claim submission.
Support review of operating room schedules.
Collect or process the information necessary for accurate and timely inpatient admission notifications, including member identification and contact details, admission and discharge information, facility and provider details, diagnosis, admission source and type, and a contact for additional information.