Job Description
Summary
The LPN Utilization Management (UM) Reviewer, in collaboration with Care Coordination, Guthrie Clinic offices, other physician offices, and the Robert Packer Hospital Business Office, is responsible for the coordination of Utilization Management (UM) processes and requirements of prior authorization/certification for reimbursement of patient care services. The responsibilities include:
- Facilitating communication between physician offices, payers, Care Coordination and other hospital departments as appropriate to obtain prior authorization required to meet contractual reimbursement requirements and to assist in ensuring generation of clean claims in a timely manner
- Securing authorization as appropriate
- Documenting payer authorization
- Facilitating issue resolution with payer sources in collaboration with other hospital departments or clinic offices as appropriate
- Demonstrating ongoing competence in payer requirements, as defined collaboratively with Patient Business Services and Care Coordination
Additionally, the position works closely with the Care Coordination department to support data collection and aggregation associated with UM processes and operations.
Experience
Minimum of five years clinical experience in an acute health care setting. Must possess strong communication and organizational skills, be able to work independently and to complete work within specified time frames. Knowledge of health benefit plans and related UM requirements preferred. Experience with CPT/ICD coding, medical record or chart auditing, and experience in utilization management processes preferred. Knowledge of computer applications (such as Microsoft word processing and spreadsheets) desirable
Education/License
Current LPN licensure or eligibility for licensure required
Essential Functions
1. Conducts validation of the authorization/certification process for elective short procedures and inpatient care services in collaboration with physician offices, hospital Business Office, Care Coordination and other hospital departments as appropriate.2. Ensures documentation and communication of authorizations and certifications as appropriate.
3. Performs routine admission and discharge notification according to payer requirements.
4. Assists to ensure compliance with documentation requirements and guidelines of third-party payers, regulatory and government agencies.
5. Develops and maintains collaborative relationships with members of the healthcare team.
- Proactively researches case findings related to payer audits of UM decisions and prepares input for supporting documentation to complete the revenue cycle process, coordinates as necessary with the hospital Business Office, physician offices, Care Coordination, Medical Director and other hospital departments as appropriate.1. Serves as liaison with payers, hospital Business Office, physician offices, Care Coordination and other hospital departments as appropriate for resolution of issues or questions.
2. Collaborates with the hospital Business Office, physician offices, Care Coordination and other hospital departments as appropriate to track and monitor the status for denials and appeals.
- Participates in performance improvement and educational activities.1. Serves as an educational resource to other members of the healthcare team with regards to changes in reimbursement, payers, and/or utilization requirements.
2. Participates in departmental long-range planning to meet the needs identified through utilization management activities.
3. Demonstrates appropriate problem solving and decision-making skills.
4. Maintains the required 8 hours of continuing education per year.
Other Duties
It is understood that this description is not intended to be all inclusive, and that other duties may be assigned as necessary in the performance of this position.
Pay Range $20.38-$31.81/hr DOE
Job Tags
Full time, Work at office,