Utilization Coordinator
Umpqua Health
Full Time - Regular
Roseburg, OR, US
POSITION PURPOSE
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The Utilization Reviewer Coordinator (URC) is a remote position that performs clinical reviews for Umpqua Health Alliance (UHA) to determine the medical necessity of requested services based on applicable Medicaid/Medicare policies and criteria. The utilization review coordinator will adhere to regulatory compliance requirements, department quality metrics and provide exceptional customer service to all internal and external customers.
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ESSENTIAL JOB RESPONSIBILITIES
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- Assesses services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.
- Analyzes clinical service requests from members or providers against evidence based clinical guidelines.
- Identifies appropriate benefits and eligibility for requested treatments and/or procedures.
- Conducts prior authorization reviews to determine financial responsibility for UHA and its members.
- Processes requests within required timelines.
- Refers appropriate prior authorization requests to Medical Directors.
- Requests additional information from members or providers in consistent and efficient manner.
- Makes appropriate referrals to other clinical programs.
- Collaborates with multidisciplinary teams.
- Adheres to Umpqua Health policies and procedures and State, Federal and local regulations.
- Maintains updated knowledge of the Oregon Administrative Rules (OAR) governing the Oregon Health Plan as well as all applicable Medicare guidelines. Referring to OHP/ Medicare websites as needed. This includes the understanding of the policies and procedures that apply to the Appeal and Grievance process and the Members Rights and responsibilities as stated by the Division of Medical Assistance Program (DMAP) as well as CMS.
- Demonstrate an ongoing understanding and current knowledge of benefits for OHP/Medicare.
- Work together with the Third-Party Recovery (TPR) coordinator regarding any member with the potential for additional insurance coverage as well as reporting any case that may reach stop loss.
- Work with Customer Care department regarding eligibility issues including when a member has a change in address or moved out of area.
- Other duties as assigned.
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GUIDING BEHAVIORS
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Accountability
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Always demonstrate the highest performance and behavior standards. Share responsibility and expect others to be accountable.
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Efficiency
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Demonstrate a proactive approach to problem identification and solutions. Be innovative and solutions oriented, improving processes while reducing costs. Demonstrate appropriate time-management skills. Optimize the use of available resources.
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Be a Team Player
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Support and assist your team members. Be available to help and learn from your team. Keep an open mind to feedback and earn trust of staff.
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Integrity
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Keep your promises, commitments, and confidences. Be honest and straightforward dealing with all issues fairly and consistently.
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Stewardship
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Adhere to all state and federal regulations relating to your position including the Health Insurance Portability and Accountability Act (HIPAA), Fraud & Abuse and Occupational Safety and Health Administration (OSHA) laws. Abide by Company policies and procedures at all times.
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CHALLENGES
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- Working with a variety of personalities, maintaining a consistent and fair communication style.
- Working in a fast-paced environment with shifting priorities.
- Coordinating resources to achieve goals and objectives.
- Remote/work from home: Must have a separate room with a locked door that can be used as a home office to ensure you and your patients have absolute and continuous privacy while you work.
- Must have the ability to provide a high-speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 10x1 (10mbs download x 1mbs upload) is required.
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QUALIFICATIONS
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Current RN, LPN, RT, LCSW, LPC, LMFT, Licensed Psychologist or equivalent license with 5 years experience with varied medical and/or behavioral health exposure and capability required. CACD I and higher for Behavioral Health position(s).
- Experience in acute care, case management, including cases that require rehabilitation, home health, behavioral health and hospice treatment strongly preferred.
- Insurance industry experience helpful, but not required. Thorough knowledge and understanding of medical and behavioral health processes, diagnoses, care modalities, procedure codes including ICD and CPT Codes, health insurance and state-mandated benefits.
- Understanding of contractual benefits and options available outside contractual benefits.
- Working knowledge of community services, providers, vendors and facilities available to assist members.
- Understanding of appropriate case management plans.
- Ability to use computerized systems for data recording and retrieval.
- Assures patient confidentiality, privacy, and health records security.
- Establishes and maintains relationships with community services and providers.
- Maintains current clinical knowledge base and certification.
- Ability to work independently with minimal supervision.
- Must be able to function as part of a collaborative, cohesive community.
- Experience following established medical guidelines required.
- Clinical knowledge of the health or social work needs for the population served.
- Demonstrated ability to identify barriers to a successful care management path.
- Ability to interact effectively and professionally with internal and external customers.
- Proficient PC Navigational skills required; solid data entry and MS Office skills required.
- Excellent critical thinking and time management skills.
- Excellent written, verbal, and interpersonal communication skills, with demonstrated ability to provide exceptional customer service to internal and external customers.
- Demonstrated transferable knowledge, skill, and ability to complete job duties independently and proficiently
- Current Oregon Drivers license required.
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PHYSICAL DEMANDS
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Typical office environment requiring standing, sitting, walking, bending, and lifting up to 25 pounds.
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PI176741462
Categories
Posted: 2022-05-03 Expires: 2022-06-03
