Utilization Review Lead

Prime Healthcare Management Inc•Ontario, CA

7d•$24 - $33

About The Position

Prime Healthcare is an award-winning health system headquartered in Ontario, California. Prime Healthcare operates 51 hospitals and has more than 360 outpatient locations in 14 states providing more than 2.5 million patient visits annually. It is one of the nation’s leading health systems with nearly 57,000 employees and physicians. Eighteen of the Prime Healthcare hospitals are members of the Prime Healthcare Foundation, a 501(c)(3) not-for-profit public charity. Prime Healthcare is actively seeking new members to join our corporate team! The Utilization review lead essentially works to coordinate the utilization review and appeals process as part of the denial management initiatives for all payors. This position will lead UR techs and be responsible for all clerical processes in the UR team including coordinating phone calls, data entry, mailing/faxing appeals and tracking data from various insurance providers and health plans regarding authorization, expedited reviews and appeals. The Lead is responsible for planning, organizing the clerical activities and ensuring timeliness, and accuracy of appeals and data tracking maneuvers. UR lead is knowledgeable in the specific functions of the appeals process and serves as a resource for co-workers. UR lead will work closely with the Corporate/Facility Utilization review teams, Business Office, Case Managers, Physicians and administration and serve as the representative of the UR team with respect to the Traditional Medicare/ Medicaid denials and the Managed care/ commercial denials. With an understanding of the scope of services for the department, the UR lead will assist the department leadership in accomplishing the set goals for the UR team. Other duties as assigned.

Requirements

Bachelor's degree or six years of relevant work experience required.
Microsoft Office proficiency.
Strong communication skills.

Nice To Haves

Completion of a medical terminology course.
Knowledge of HIPAA regulations.

Responsibilities

Coordinate the utilization review and appeals process as part of the denial management initiatives for all payors.
Lead UR techs and be responsible for all clerical processes in the UR team including coordinating phone calls, data entry, mailing/faxing appeals and tracking data from various insurance providers and health plans regarding authorization, expedited reviews and appeals.
Planning, organizing the clerical activities and ensuring timeliness, and accuracy of appeals and data tracking maneuvers.
Knowledgeable in the specific functions of the appeals process and serves as a resource for co-workers.
Work closely with the Corporate/Facility Utilization review teams, Business Office, Case Managers, Physicians and administration and serve as the representative of the UR team with respect to the Traditional Medicare/ Medicaid denials and the Managed care/ commercial denials.
Assist the department leadership in accomplishing the set goals for the UR team.
Other duties as assigned.