Job Type

Full-time

Description

Responsible for applying clinical and benefits administration policy guidelines to requests for authorizations.

Provides accurate, prompt, and appropriate medical authorizations to requests for Patients, Insurance Companies, and Providers.

Ensures that clinical documentation complies with federal laws.

Demonstrates the mission of HRMC by displaying REACH, our core value system:

• Respectful - We value the unique talents, ideas, contributions, and circumstances of each individual.
• Engaged - We value being active, positive participants at work and in our communities.
• Available - We value providing local access to care for our communities while being present for each other.
• Competent - We value knowledgeable, people-centered, innovative, and technology driven teams.
• Helpful - We value always helping others with kindness and compassion.

Essential Job Functions:

Demonstrates understanding that patients, physicians, visitors, and other hospital staff are customers, and consistently seeks to exceed customers' expectations.

Uses established criteria to conduct preliminary decision review for services requiring prior authorization

Applies clinical and benefit administration policy guidelines to requests for authorizations

Assesses the need for additional information to complete a service decision request

Enters authorizations into the EMR data system to ensure timely review of and downstream claims processing

Works closely with Care Coordinator and Medical staff to escalate decisions that require clinical review and oversight

Communicates results of reviews in the EMR UR space for the primary care team and clinical reviewers

Handles all authorization requests timely and accurately, adhering to performance measures

Follows department and organizational policies and procedures as well as adheres to all applicable regulatory, contractual, and compliance requirements

Fulfills duties as above within service standard turnaround times

Analyzes medical information and trains staff in medical documentation practices

Facilitates the Utilization Management Program, Committee, and Plan

Other Job Duties:

Promotes and maintains confidentiality of information regarding patients, families, health care personnel and the facility.

Participates in hospital's quality, risk and utilization plan.

Qualifications: (Minimum Education and Experience)

Associate's degree or equivalent experience - bachelor's degree (preferred)

2+ years professional work experience in health care, managed care, or insurance

Education, training, or experience as a medical coder, medical billing, Insurance Coordinator or other relevant clinical background highly preferred

Knowledge, Skills, and Abilities:

Familiarity with utilization management review preferred

Knowledge of CPT and ICD coding highly preferred

Flexibility and understanding of individualized care plans

Excellent interpersonal, verbal, and written communication skills

Ability to work independently and make decisions

Work in a team-based environment

Working knowledge of and ability to navigate through the healthcare system (insurances, Medicare, Medicaid, physician office operations)