Utilization Management Coordinator

Primary City/State: Virtual Arizona

Category:

Case Management

Shift:

Day

Department:

Case Management

• Remote
• Monday - Friday 7:30am - 4:00pm

Great care starts with great people. (Like you.)

At HonorHealth, you’ll find something special. From humble beginnings in 1927 to one of Arizona’s largest nonprofit healthcare systems, our culture is built on warmth and neighborly kindness. Behind every smile is a highly skilled professional with deep expertise and an unwavering dedication to what matters most — caring for the health and well-being of people and communities across the greater Phoenix area.

Responsibilities:

JOB SUMMARY

Under the direction of the Network Manager for Utilization Management, assists in the administration of Utilization Management functions to include, but not limited to, organization and prioritization of workflow, internal and external department communications, critical information interpretation and tracking follow up, research, and report creation. The position primarily supports UM operations and communication with payers, in order to effectively gain approval of admissions via the clinical review and appeal processes. Secondarily, this position supports Care Coordination department efforts in optimizing department communications from payers, in an efficient and effective workflow process. Ensures all inbound faxes are handled timely and appropriately based on payer requirements. Ensures approvals are in alignment with current patient class and escalates any received payer communication contrary to such. Communicates with related Network departments in the event of account discrepancies concerning payer coverage and/or admission notification issues. Documents EMR/EPIC appropriately according to department standards. Collaborates and communicates with UM nurses regarding payer requirements for clinical documentation in order to secure appropriate level of authorization for the inpatient or observation admission. Identifies, interprets, and initiates concurrent denial documentation and operational workflows, to include the scheduling of Physician Advisor peer-to-peer activity with payers.

ESSENTIAL FUNCTIONS

• Performs a variety of routine clerical and revenue optimizing activities according to department workflows. Meets defined productivity standards. Works accounts from assigned WQs. Monitors RightFax daily for inbound faxes from payers. Renames inbound faxes, adhering to department naming conventions. Uploads payer approvals, bed days and denials to appropriate patient’s account. Documents EMR/EPIC Auth/Cert and Communications. Faxes initial or continued stay clinicals to payers utilizing appropriate method ensuring payer requirements are met. Follows up on fax fails until successfully resolved. When HIPPA breaches occur, fills out Compliance department breach reporting form and submits chart correction. Communicates with Preservices team if patient’s coverage is termed or unclear. Continuously monitors deferred accounts; follows up timely with payers to obtain additional approved days. Collaborates with external payers in securing approvals, as well as internal team members, UM nurses and others in Care Coordination departments to achieve business needs of the department and in support of revenue optimization. In all areas of responsibility, communicates barriers and escalates issues. Facilitates clinical data requests and documents appropriately. Coordinates concurrent denial resolution with nursing and physician advisor team. Facilitates peer to peer review with payer as directed.
• Retrieves utilization management clinical requests and handles each appropriately according to department standards. Escalates patient calls to leadership and documents in EPIC/EMR.
• Performs other duties as assigned (reports, research, meeting scribe, new hire onboarding, etc.)

EDUCATION

• High School Diploma or GED Required
• Associates Preferred

EXPERIENCE

• 1 year Clerical support Required
• 1 year Administrative support in a healthcare field (e.g., case management, utilization review, medical insurance, medical office front desk, hospital business office, preservices, admitting, registration, billing, collections) Preferred

LICENSE AND CERTIFICATIONS

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