Utilization Review Technician III

Organization:

MPHS-Mills-Peninsula Medical Center

Position Overview:

Acts independently to perform and coordinate all activities related to the billing, denials, and appeals of all types. Reports out monthly (and as needed) on denials and other utilization management subjects.

Job Description:

These Principal Accountabilities, Requirements and Qualifications are not exhaustive, but are merely the most descriptive of the current job. Management reserves the right to revise the job description or require that other tasks be performed when the circumstances of the job change (for example, emergencies, staff changes, workload, or technical development).

JOB ACCOUNTABILITIES:

UTILIZATION MANAGEMENT:

• Processing patient authorizations, concurrent reviews, denials and appeals
• Performs prospective, concurrent and retrospective reviews to determine medical necessity and appropriate service locations and means of care delivery.
• Performs cost benefit analysis of care options. Interviews client/responsible party to determine preference and provide information on financial and social responsibilities to support the client’s care. Arranges linkages with community resources and alternate services for clients with limited insurance benefits or personal resources.
• Issues denials to client/responsible party following regulatory guidelines and facility protocols. Informs client/responsible party of right of appeal and the appeal process.
• The incumbent must be familiar with third party regulations and requirements, managed care concepts, and current practices, as well as utilization review principles and practices.

DAILY OPERATION:

• Directs and oversees the daily operations of utilization management
• Functionally supervises staff using effective leadership techniques consistent with Sutter philosophies, such as coaching with positive suggestion, listening, being timely with corrective action, and remaining calm and objective.
• Insures that work hours are scheduled and assigns work duties to maximize resources through direct involvement and delegation.
• Exhibits a customer/supplier philosophy that emphasizes both internal and external relationships; identifies both customer and supplier needs/expectations and strives to exceed them.
• Actively participates in, and encourages others to utilize creative and innovative approaches to accomplish tasks.
• Collaborates with physicians to expedite timely resolution of situations such as inappropriate admissions, need for lower level of care, and home health referrals.

EXTERNAL RELATIONSHIP:

• Interface and develop relationships with commercial payers.
• Maintains current knowledge of third party reimbursement and regulation changes by collaborating and coordinator with Sutter’s Patient Access and Financial Services (PAFS) department.
• Develops and maintains ongoing relationships with all payer sources in order to effectively anticipate and resolve problems using effective communication.

OTHERS:
Denial variance reporting and analysis, and reporting outcomes to key stakeholders
Demonstrates commitment to total quality management through knowledge of its precepts, skillful workplace applications and continuous organizational improvement.
Provides timely data and reports to CAO, department directors,managers, finance administration and other key stakeholders.
Demonstrates communication and complex problem resolution skills to maintain effective working relationships with hospital departments, physicians, outside agencies, and the public. Effectively uses the team approach to problem resolution on issues crossing department lines.
Participates in regularly scheduled department meetings to acquire updated information on the organization’s overall goals and issues. Keeps staff appropriately informed.


EDUCATION:

[Equivalent experience will be accepted in lieu of the required degree or diploma]

Other: Graduate of an accredited Vocational Nursing Program or equivalent education/experience

OR Other: Graduate of an accredited Psychiatric Technician Program


CERTIFICATION & LICENSURE:

LVN-Licensed Vocational Nurse

OR PSYT-Psychiatric Technician


TYPICAL EXPERIENCE:

2 years of recent relevant experience.


SKILLS AND KNOWLEDGE:

Ability to work independently with a minimum of direction.

Critical thinking skills necessary to provide utilization review/discharge planning services appropriate to patients with complex medical, emotional and social needs.

Interpersonal, organizational and time management skills.

Effective oral and written communication skills.


PHYSICAL ACTIVITIES AND REQUIREMENTS:

See required physical demands, mental components, visual activities & working conditions at the following link: Job Requirements

Job Shift:

Days

Schedule:

Full Time

Shift Hours:

8

Days of the Week:

Monday - Friday

Weekend Requirements:

As Needed

Benefits:

Yes

Unions:

No

Position Status:

Non-Exempt

Weekly Hours:

40

Employee Status:

Regular

Number of Openings:

1

Sutter Health is an equal opportunity employer EOE/M/F/Disability/Veterans.

Pay Range is $45.18 to $54.21 / hour

Qualified applicants with arrest and conviction records will be considered for employment. Applicants for specific positions are still required to disclose certain convictions during the application process, and those convictions may also be considered in determining eligibility for employment in accordance with applicable law.

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