Job Title: Utilization Management Coordinator | Patient Access Management | Fargo
State: North Dakota
Department : PATIENT ACCESS MANAGEMENT
Job Schedule: Full Time
Hours Per Shift: 8 hr
Monitors the utilization of resources, risk management and quality of care for patients in accordance to established guidelines and criteria for designated setting and status. Collection of clinical information necessary to initiate commercial payor authorization.
Obtain and maintain appropriate documentation concerning services in accordance to reimbursement agency guidelines. Consult with interdepartmental departments and staff to assure all relevant information regarding patient status and diagnosis are accurately reported. Provide information via multiple sources of technology applications to insurance companies and contracted vendors to assure authorization for patients.
May participate in providing assistance in financial aid and/or counseling if applicable.Accurately recognizes coding principle diagnosis and principle procedures including complicating/comorbid diagnoses for accurate diagnosis-related group (DRG) assignment during hospitalization. Monitors patient hospitalization to ensure prospective payment limit is not exceeded without due notice to the attending physician. May also need to notify physician and patient of authorization denials.
Inputs collected data into computer system for insurance communication, DRG grouping, data abstraction for monitoring and evaluation, and when applicable, Medicare National and Local Coverage Determinations (NCD/LCD), and Joint Commission (TJC) required functions and credentialing. Assists medical records coding personnel as needed to correctly identify diagnoses and procedures, and obtains physician documentation as needed. Monitors patient hospitalization to ascertain medical necessity and appropriateness.
Assists with retrospective review of specified charts as required. Ability to interact on an interpersonal basis with both providers and nursing staff. Demonstrates proficiency with computers, Microsoft applications, and additional designated technology within the department.
Will perform multiple administrative duties including accurate record keeping and electronic data management when needed. Ability to work with growth and development needs of pediatric to geriatric populations. #featuredjob
Applies available tools and resources to work efficiently. Assesses common problems and associated approaches to resolution.
Delivers written and oral communication, responds to questions and concerns, and produce specific outcomes and impact. Demonstrates an ability to meet own responsibilities. Explains the best practices, key processes and benchmarks for a specific insurance product.
Follows-up with customers to answer questions and ensure satisfaction. Maintains a sense of urgency and a positive attitude. Maintains sense of commitment to success, personal achievement and satisfaction.
Operates and maintains standard office equipment such as copiers, faxes, phones. Presents a professional image, especially when dealing with customers.
Full-time, 40 hours a week. The UM Coordinator will be required to work primarily day hours, but may be required to work some evenings to ensure contact with case managed members.
Manage and complete authorization within the work queues; Assist with and manage insurance denials; Review medical policies and review for medical necessity for scheduled procedures; Verify insurance coverage through established methods; Perform other duties as assigned. Works in an office environment and basically telephonic/computer; May occasionally have face to face contact with members in the office setting.
Currently holds an unencumbered Licensed Practical Nurse (LPN) license with State Nursing board and/or possess multi-state licensure privileges, or Registered Health Information Technician (RHIT) or a coding certification (CCS, CCSP, CPC, CPCH, COC, CAC) required. Obtains and subsequently maintains required department specific competencies and certifications.
Appropriate education level required in accordance with licensure. Seven years of relevant experience, superior communication and interpersonal skills. Minimum one year healthcare or clinical experience required. Specific background or experience in healthcare reimbursement, insurance industry, and/or authorization experience would be critical to the success in this role and preferred.
About Sanford Health:
At Sanford Health, we are dedicated to the work of health and healing.
Every day, we show that commitment by delivering the highest quality of care to the communities we serve.
We are leaders in health care and strive to provide patients across the region with convenient access to expert medical care,
leading-edge technologies and world-class facilities.
In addition to strong clinical care, we are also committed to research,
education and community growth. We engage in medical research to not only discover innovative ways to provide care, but also cures for common diseases.
We continuously seek new ways to achieve our vision of improving the human condition
here in your community, across the region and around the world.
The entire team at Sanford Health recognizes the value of healthy families
and communities. We continue to gain momentum and expand our reach. Together, we can make a positive difference now, and in the future.
Sanford is an EEO/AA Employer M/F/Disability/Vet.
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State: North Dakota
Job Function: Revenue Cycle
Job Schedule: Full Time
Req Number: req26376