Utilization Review Lead

Prime Healthcare • Ontario, CA

3d • $24 - $33

About The Position

Overview 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! Responsibilities 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.

Benefits

• Prime Healthcare offers competitive compensation and a comprehensive benefits package that provides employees the flexibility to tailor benefits according to their individual needs.
• Our Total Rewards package includes, but is not limited to, paid time off, a 401K retirement plan, medical, dental, and vision coverage, tuition reimbursement, and many more voluntary benefit options.
• A reasonable compensation estimate for this role, which includes estimated wages, benefits, and other forms of compensation, is $24.31 to $33.00.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 5,001-10,000 employees