Utilization Review Specialist

Utilization Review Specialist

At the Innovative Hematology (IHI), we offer a future where people with rare blood disorders flourish. Our experts provide the highest quality comprehensive services and holistic care to patients with bleeding, clotting and other hematologic disorders, and to their families.

As the Utilization Review Specialist, you will be responsible for verifying patient eligibility with payers and works in conjunction with the pharmacy staff and providers to coordinate referrals, precertification, or prior authorizations for medications.

The Opportunity

• Secure appropriate medical documentation requested by third-party insurance providers.
• Verify insurance coverage for pharmacy benefits.
• Prior to expected date of service, prepare and submit precertification and prior authorizations to payers. Follow up with patients, insurance companies, pharmacy staff, and physicians regarding denials, as well as working with providers and staff to resubmit paperwork to obtain a determination.
• Notify patients, providers and front office staff prior to date of service if referrals, precertification, or prior authorizations are not approved.
• Remain up to date on outpatient billing and benefit changes for third-party insurance carriers. Maintain compliance with all government and non-government insurance company policies and procedures as they relate to outpatient services.
• Ensure correct reporting of patient diagnosis and procedure coding.
• Ensure compliance with LCD/NCDs. Communicate issues with medical necessity or other findings to providers/fellow team members, and utilization review supervisor as needed.
• Prepare and submit pharmacy claims to third party insurance carriers.
• Secure appropriate medical documentation as required by third party insurance carriers.
• Follow up with third party insurance carriers on unpaid claims or balances.
• Research payer regulations and claim guidelines on payment and claim submission criteria to ensure compliant billing practices by utilizing website and associated tools established for payers as applicable.
• Verify insurance coverage for pharmacy services prior to services being rendered.
• Ensure accurate and through documentation of steps taken to resolve prior authorization and claim issues are recorded in billing software(s).
• Monitor claims for accuracy and authorization. Communicate claim issues to team lead and/or utilization review supervisor on a regular basis.
• Work with team lead/utilization review supervisor to establish goals and communicate associated progress as needed.

Knowledge:

• Billing practices, clinic policies, and operating procedures.
• Coding and clinic operating policies.

Skills:

• Proficient in clinical and administrative software systems.

Abilities:

• Understand and interpret policies and regulations.
• Read and interpret medical charts.
• Review documents for accuracy and completeness.
• Communicate effectively and collaborate with staff and providers.