Primary City/State:
Arizona, Arizona
Department Name:
Denial Recovery-Corp
Work Shift:
Day
Job Category:
Revenue Cycle
A rewarding career that fits your life. As an employer of the future, we are proud to offer our team members many career and lifestyle choices including remote work options. If you’re looking to leverage your abilities – you belong at Banner Health.
The utilization Management Representative will process clinicals to send to payers while the patient is in house, enter authorizations and enter concurrent denials for the RNs.
Systems frequently used: Cerner, XSOLIS, MS4
Schedule: Monday – Friday 8:30am – 5pm AZ Time
This can be a remote position if you live in the following states only: AK, AZ, AR, CA, CO, GA, FL, IA, ID, IN, KS, KY, LA, MD, MI, MO, MN, MS, NH, NM, NY, NC, ND, NE, NV, OH, OK, OR, PA, SC, TN, TX, UT, VA, WI, WV, WA, & WY
Within Banner Health Corporate, you will have the opportunity to apply your unique experience and expertise in support of a nationally-recognized healthcare leader. We offer stimulating and rewarding careers in a wide array of disciplines. Whether your background is in Human Resources, Finance, Information Technology, Legal, Managed Care Programs or Public Relations, you’ll find many options for contributing to our award-winning patient care.
POSITION SUMMARY
This position assists in the administration of Utilization Management functions to include organization of workflow, communications with the system, critical information tracking and links with external payor representatives. This position is focused on supporting the role of utilization management process to protect the organization’s financial goals. This position works closely with utilization review staff, insurance companies, patient financial services and central billing office.
CORE FUNCTIONS
1. Handles incoming requests for patient medical records, notifications of authorizations and denials and other related communications. Receives and verifies requests and external communications, initiates insurance verification, gathers and submits all information necessary for certifications for medical necessity. Provides on-going follow-up of requests, up to and following patient discharge.
2. Builds clinical response to external requests using information in patient medical record to provide minimum data necessary to coordinate authorizations. Follow up communication with insurance companies with information as required and documents responses for follow up as identified.
3. Performs data entry of patient intake information into computer system. Records insurance information and authorization requirements and notes information in the identified data entry systems.
4. Facilitates problem solving with hospitals, providers, referral sources, insurance companies, and clinical staff. Assists in the maintenance and communication of changing payor and referral source information specific to coordination of patient needs.
5. Ensures communications between payor and hospital occurs per payor request. This includes accurate transcription and routing of third party payor communications.
6. Abstracts information from patient medical records pertaining to patient identification, treatments, procedures and outcome as required by duties assigned. Documents accurately and timely in electronic record of insurance review activities and notifications of authorizations and denials.
7. Participates in departmental improvements, Banner initiatives and performs data collection for measurement of projects.
8. Works collaboratively with team members; promotes collaborative relationships with commercial payors and external customers.
9. Works under general supervision. Confers with supervisor on any unusual situations. Positions are corporate or InTouch based with no budgetary responsibility. Internal customers: All levels of nursing management and staff, medical staff, and all other members of the interdisciplinary health care team. External Customers: Insurance providers, county and governmental agencies and any reimbursement related entities. Non-clinical staff are not responsible for conducting any UM review activities that require interpretation of clinical information. Licensed health professionals are available and indicate process for the oversight. For initial screening, the organization limits use of non-clinical administrative staff to the following; Performance of review of service request for completeness of information, Collection and transfer of non-clinical data, Acquisition of structured clinical data, Activities that do not require evaluation or interpretation of clinical information. The organization ensures that licensed health professionals are available to non-clinical administrative staff while performing initial screening.
MINIMUM QUALIFICATIONS
High school diploma/GED or equivalent working knowledge.
The position requires a proficiency level typically achieved with 3 years experience in healthcare as a Nursing Asst, Medical Asst, Health Unit Coordinator, Patient Care Tech, etc.
Requires an understanding of medical terminology. Must demonstrate effective communication skills, human relations skills, strong organizational and time management skills and flexibility in responding to multiple demands.
PREFERRED QUALIFICATIONS
Bilingual, preferred in some assignments.
Additional related education and/or experience preferred.
EEO Statement:
EEO/Female/Minority/Disability/Veterans
Our organization supports a drug-free work environment.
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