Utilization Review Coordinator (Remote)

Job Description

Community Health Systems is one of the nation's leading healthcare providers. Developing and operating healthcare delivery systems in 40 distinct markets across 15 states, CHS is committed to helping people get well and live healthier. CHS operates 71 acute-care hospitals and more than 1,000 other sites of care, including physician practices, urgent care centers, freestanding emergency departments, occupational medicine clinics, imaging centers, cancer centers and ambulatory surgery centers.

Summary:

This role serves as a payor liaison to ensure that an authorization for services is obtained from payor, if required and communication with commercial payers is completed in a timely manner and is available to the Utilization Review Clinical Specialist for administrative, payor related tasks.

Essential Duties and Responsibilities:

• Submits initial assessments, continued stay assessments, and payer requested reviews following the established policies and regulations governing this process to ensure the payor receives notification and documentation that patients meet medical necessity for hospitalization at the correct level of care.

• Communicates with commercial payers per request of payer/hospital policy and procedure. Provides complete and concise communication submitting the critical elements that will establish medical necessity, provided by the UR Clinical Specialist, to ensure timely authorization and reduce the potential for denials. Documents all activities in the case management system(s).

• The Utilization Review Coordinator follows-up for an approval/denial if no reply is received within 12-24 hours. This follow-up may be by phone or using payer internet portals.

• Documents all actions and activities in the case management software system used by the hospital. This documentation includes, but is not limited to, escalations, avoidable days, payer contacts, authorization numbers, denials etc. Documentation may also be made in other systems as required based on hospital and/or corporate policies/procedures.

• In the event of concurrent denials that cannot be resolved through provision of additional clinical information and/or documentation, the Utilization Review Coordinator arranges a Peer to Peer discussion according to hospital and/or corporate direction and payer requirements unless the hospital's internal secondary review process indicates the need to downgrade the visit. The arrangements may range from actually coordinating a meeting time or simply sharing contact information with both parties. Results of the Peer to Peer are to be gathered from the physician presenting after the call and documented in the case management system by the Utilization Review Coordinator.

• Utilization Review Coordinator closes out each hospital stay after the patient's discharge by providing the documentation and/or dates required by the payer. The Utilization Review Coordinator will also ensure that documentation about authorizations, denials, delays, and other reviews are complete and understandable for the billing and other reviewers who may later review this case. Cases with any incomplete Peer to Peer or authorization processes are placed on hold so that these processes can be completed prior to the billing of the claim.

• Promptly notifies the Denials and Appeals RN & Staff at respective Shared Service Center (SSC) of any denials, potential denials, or additional information requests from insurance companies.

• Utilization Review Coordinator communicates with the Utilization Review Clinical Specialist and facility case manager(s) (i.e. licensed social workers, discharge planners, etc.) in -person, telephonically, and/or through the case management software to ensure effective collaboration between all disciplines managing a patient's care.

Qualifications:

• Required Education: High School Diploma

Preferred Education: Bachelor's Degree

• Required Experience: At least 2 years related experience and/or training

Preferred Experience: 3 plus years Utilization review experience

• Required License/Registration/Certification: N/A

Preferred License/Registration/Certification: N/A

• Computer Skills Required: Data entry skills; Demonstrable skills with Google Docs, Google Sheets, Microsoft Word, Microsoft Excel software and email applications.

• Language: Ability to read and comprehend simple instructions, short correspondence, and memos. Ability to write simple correspondence. Ability to effectively present information in one-on-one and small group situations to customers, clients, and other employees of the organization.

• Math: Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.

• Reasoning: Ability to apply common sense understanding to carry out detailed but uninvolved written or oral instructions. Ability to deal with problems involving a few concrete variables in standardized situations.

Physical Demands:

In order to successfully perform this job, with or without a reasonable accommodation, the following are outlined below:

• The Employee is required to read, review, prepare and analyze written data and figures, using a PC or similar, and should possess visual acuity.

• The Employee may be required to occasionally climb, push, stand, walk, reach, grasp, kneel, stoop, and/or perform repetitive motions.

• The Employee is not substantially exposed to adverse environmental conditions and; therefore, job functions are typically performed under conditions such as those found within general office or administrative work.