Utilization Management Representative

Banner Health•Mesa, AZ

About The Position

A rewarding career that fits your life. As an employer of the future, we are proud to offer our team members many career and lifestyle choices including remote work options. If you’re looking to leverage your abilities – you belong at Banner Health. The utilization Management Representative will process clinicals to send to payers while the patient is in house, enter authorizations and enter concurrent denials for the RNs. Systems frequently used: Cerner, Microsoft Office , MS4 Schedule: Monday - Friday 8:30am - 5pm AZ Time Banner Staffing Services (BSS) offers Registry/Per Diem opportunities within Banner Health. Registry/Per Diem positions are utilized as needed within our facilities. These positions are great way to start your career with Banner Health. As a BSS team member, you are eligible to apply (at any time) as an internal applicant to any regular opportunities within Banner Health. Learn more at https://youtu.be/Pu3VR3tGlw0 As a valued and respected Banner Health team member, you will enjoy: Competitive wages Paid orientation Flexible Schedules (select positions) Fewer Shifts Cancelled Weekly pay 403(b) Pre-tax retirement Resources for living (Employee Assistance Program) MyWell-Being (Wellness program) Discount Entertainment tickets Restaurant/Shopping discounts Registry/Per Diem positions do not have guaranteed hours and no medical benefits package is offered. Completion of post-offer Occupational Health physical assessment, drug screen and background check (includes employment, criminal and education) is required. POSITION SUMMARY This position assists in the administration of Utilization Management functions to include organization of workflow, communications with the system, critical information tracking and links with external payor representatives. This position is focused on supporting the role of utilization management process to protect the organization’s financial goals. This position works closely with utilization review staff, insurance companies, patient financial services and central billing office.

Requirements

High school diploma/GED or equivalent working knowledge.
The position requires a proficiency level typically achieved with 3 years experience in healthcare as a Nursing Asst, Medical Asst, Health Unit Coordinator, Patient Care Tech, etc.
Requires an understanding of medical terminology.
Must demonstrate effective communication skills, human relations skills, strong organizational and time management skills and flexibility in responding to multiple demands.

Nice To Haves

Bilingual, preferred in some assignments.
Additional related education and/or experience preferred.

Responsibilities

Handles incoming requests for patient medical records, notifications of authorizations and denials and other related communications.
Receives and verifies requests and external communications, initiates insurance verification, gathers and submits all information necessary for certifications for medical necessity.
Provides on-going follow-up of requests, up to and following patient discharge.
Builds clinical response to external requests using information in patient medical record to provide minimum data necessary to coordinate authorizations.
Follow up communication with insurance companies with information as required and documents responses for follow up as identified.
Performs data entry of patient intake information into computer system.
Records insurance information and authorization requirements and notes information in the identified data entry systems.
Facilitates problem solving with hospitals, providers, referral sources, insurance companies, and clinical staff.
Assists in the maintenance and communication of changing payor and referral source information specific to coordination of patient needs.
Ensures communications between payor and hospital occurs per payor request.
This includes accurate transcription and routing of third party payor communications.
Abstracts information from patient medical records pertaining to patient identification, treatments, procedures and outcome as required by duties assigned.
Documents accurately and timely in electronic record of insurance review activities and notifications of authorizations and denials.
Participates in departmental improvements, Banner initiatives and performs data collection for measurement of projects.
Works collaboratively with team members; promotes collaborative relationships with commercial payors and external customers.
Works under general supervision.
Confers with supervisor on any unusual situations.
Positions are corporate or InTouch based with no budgetary responsibility.
Internal customers: All levels of nursing management and staff, medical staff, and all other members of the interdisciplinary health care team.
External Customers: Insurance providers, county and governmental agencies and any reimbursement related entities.
Non-clinical staff are not responsible for conducting any UM review activities that require interpretation of clinical information.
Licensed health professionals are available and indicate process for the oversight.
For initial screening, the organization limits use of non-clinical administrative staff to the following; Performance of review of service request for completeness of information, Collection and transfer of non-clinical data, Acquisition of structured clinical data, Activities that do not require evaluation or interpretation of clinical information.
The organization ensures that licensed health professionals are available to non-clinical administrative staff while performing initial screening.