Utilization Review Technician - UR-Case Management

The County of Riverside's RUHS-Medical Center Department is seeking a Utilization Review Technician to support the UR Case Management Division in Moreno Valley. Under general supervision, performs a variety of clerical and data collection tasks and acts as a liaison between providers, medical staff, and insurance plans in support of Utilization Management and professional staff at Riverside University Health System (RUHS). Performs other related duties as required. The Utilization Review Technician is a journey level classification and reports to an appropriate supervisory or manager level position. Incumbents respond to inquiries and concerns of the health plan members and serve as the primary liaison between the health plan member and network providers. In addition, this class monitors patient treatment records and follows up with physicians or nursing staff to ensure that documentation is provided or a determination is made as to medical necessity and appropriateness of services. Essential Duties General office and administrative support Inventory control and purchasing Scheduling and timekeeping Other duties as assigned Responsibilities Record intake information on the phone from providers requesting referral and/or authorization and refer requests to nursing staff, and/or Medical Director, or give authorization according to specified criteria following physician or nursing staff directions. Monitor and maintain Medi‑CAL Treatment Authorization Requests (TARs) backlog and Commercial Insurance backlog. Refer TARs to Case Manager for resubmission. Act as a liaison and resource to other departments, contracted hospitals, insurance companies, subsidized programs, etc. relative to the work of the department. Monitor insurance listed within patients Emergency Medical Records (EMR) and notify Integrated Care Management (ICM) team members regarding insurance changes; assist in obtaining authorizations and approval for inpatient stays and document authorizations in the EMR. Work with medical staff to complete patient charts and forms; compare medical record documentation with professional standards of care, as outlined by the utilization review nurse manager or physician. Issue Important Message (IM) and Medicare Outpatient Observation Notice (MOON) letters for Medicare beneficiaries. Coordinate Durable Medical Equipment (DME) prescriptions with RUHS staff and insurance companies/payor source. Monitor and maintain California Children Services (CCS) database, document authorizations/denials from CCS and make referrals for all patients under 21 with qualifying CCS diagnosis. Promote continuity of care by transmitting all Discharge Summaries to insurance providers. Desired Qualifications Microsoft 365 proficiency (Word, Excel, Teams) Strong organizational skills Work Schedule: Will be discussed during the interview; Tentative 5/40, 8:00 AM‑4:30 PM, rotating weekends and holidays required. Education Graduation from high school or attainment of a satisfactory score on a G.E.D. test. Experience Option I – Six months of clinical, billing, or medical office administration experience in a healthcare or a Health Maintenance Organization. Option II – One year of clerical experience. Knowledge of General policies of health coverage limits related to managed care and HMO standards; hospital registration, reimbursement, or referral practices and procedures. Eligibility requirements of subsidiary programs such as Managed Care, Medi‑Cal, Medicare, CCS, etc. General interviewing techniques and telephone etiquette. Computer programs, including use of database and word processing. Proper English usage, style, grammar, punctuation, and spelling. Ability to Learn specialized medical terminology, project indicators and office procedures. Perform a variety of clerical duties and work effectively under stressful conditions. Communicate effectively in providing information and assisting the public. Interact with public service providers, members of the public and staff in a courteous, effective manner. Other Requirements Possession of a valid California Driver’s License may be required. #J-18808-Ljbffr County of Riverside