Utilization Management Resource Coordinator - Sharp Spectrum Corporate Offices Va

Hours

Shift Start Time: Variable

Shift End Time: Variable

AWS Hours Requirement: 8/40 - 8 Hour Shift

Additional Shift Information:

Weekend Requirements: As Needed

On-Call

Required:

No

Hourly Pay Range (Minimum - Midpoint - Maximum): $28.170 - $35.210 - $39.430

The stated pay scale reflects the range that Sharp reasonably expects to pay for this position. The actual pay rate and pay grade for this position will be dependent on a variety of factors, including an applicant’s years of experience, unique skills and abilities, education, alignment with similar internal candidates, marketplace factors, other requirements for the position, and employer business practices.

This position supports the system centralized utilization management department to meet division and organizational objectives, facilitate effective communication between department staff and the internal and external customers to the department, including but not limited to the business office, revenue cycle, physicians and payers. This position is accountable to ensure timely follow up on payer requests for clinical documentation, optimal inbound and outbound fax management to mitigate denials and ensure established timeliness response metrics are met, and reconciliation of hospital authorizations.

Identification and escalation of concerns to the ICM System Centralized Utilization Management team to mitigate denials. Assists in capturing administrative days under the direction of the UM CM s. A key member of the UM customer service team to meet and exceed the customer s expectations.

• H.S. Diploma or Equivalent

• Other Health related education.
• Other Successful completion of Medical Assistant Program or equivalent.
• 2 Years hospital experience.
• 2 Years Medi-Cal experience.

• Monitor Utilization Management Queues
• Works with the other members of the UM team to monitor timely management of the UM queues. Escalates to management when queues are outside of established turnaround time frames.
• Verifies current insurance plan eligibility. Assists the UM CM’s to report inaccurate insurance information on the facesheet.
• Reviews patient list and prioritizes/plans for the day.
• Contributes to the continuous improvement initiatives of the system centralized utilization management team to deliver quality interventions in a timely manner.
• Maintains proactive communications with insurance representatives, UM CM’s and TP CM teams at the site level.
• Maintains a current payer contact list to support utilization management activities.
• Maintains passwords and access to payer portals to ensure timely UM authorization capture.
• Teamwork and Collaboration
• Acts as facilitator between payors and UM team members.
• Ensures UM team members are updated daily and thought out the day as needed.
• Keeps the ICM UM Leadership aware of inability to complete assigned duties or tasks.
• Responsible for timely and accurate retrieval and appropriate action on departmental phone messages and necessary fax communication.
• Work closely with revenue cycle to ensure the latest reimbursement and contract information is available to the utilization managers.
• Work closely with the revenue cycle to make sure all are aware of denials real time.
• Supports staff and leadership to meet department objectives.
• Database Management
• Assists with the processing of letters of authorization, appeal or denial.
• Prepare databases and written reports for leads, manager, and director in a timely manner as requested and within the scope of work.
• Initiates and participates in the creation and development of forms and lists.
• Assist UM case managers and physician advisors with denial cases, setting up peer to peer reviews as needed.
• Must demonstrate attention to detail and accuracy.
• Department Operations
• Ensures UM staff have appropriate resources and information to expedite smooth transition to through continuum and optimize third party payer reimbursement.
• Monitor authorization for all patients in-house to ensure reimbursement and payment for correct level of care.
• Monitor completion of retro reviews and notifies lead of reviews pending by noon the second business…