Utilization Reviewer - Utilization Management Willowbrooke (Days)

Communicating with Insurance companies, other Tanner departments, and co-workers about payment issues of patients.
Keeping organized up to date documentation on patients.
Under general direction, the Case Manager coordinates a multidisciplinary approach to organize and coordinate effective, efficient quality care.
The Case Manager ensures the availability of sufficient clinical and financial information to enable the health care team to function efficiently and effectively within the continuum of care and the continuum of resources.
The Case Manager identifies pertinent roles for and encourages the active participation of, the clinical, administrative, and ancillary staff in the case management process.
The Case Manager serves as a liaison among all functions related to case management including Administration, Medical Staff, Nursing Service, and Fiscal Services.


Education

Bachelor's Degree

Qualifications

*Ability to concentrate on tasks and meet deadlines

*Ability to confidentially maintain all information

*Ability to deal with the public and individuals within the organization

*Basic data entry skills preferred; including experience using a computer

*Basic knowledge of and skills applying principles of abnormal psychology and mental health problems

*College-level reading and comprehension, writing, and mathematical skills.


*Familiarity with psychological, sociological, and medical terminology's

*Organization and time management skills

*Skills in analyzing and evaluating information, problem-solving skills, excellent oral communication skills, and legible handwriting.


Area of Responsibilities
*Documents calls and related information on designated forms
*Establishes and maintains positive relationships with patients, physicians, allied health professionals (case managers) and peers.
Responsible for responding as needed to insurance companies in a timely manner.

*Responsible for documenting insurance information/authorization numbers in Meditech.
Responsible for documenting daily reviews/precertifications in UM calendar.

*Responsible for verifying that all indigent patients have been referred to Patient Financial Assistance Program prior to admission.
Confirming with the Business Office that patient has been approved for Patient Financial Assistance as well as percentage approval prior to patient's admission.
Responsible for documenting all information in designated area.

*Responsible for verifying, pre-certing, and coordinating all insurance information for admissions within designated program.
Responds to telephone and face-to-face inquires about insurance or payment questions.
Responsible for Medicaid and Medicare monthly verification for assigned program, this task is time sensitive and must be completed with in the first five calendar days of the month.

*Assists Department Manager in training activities and other special projects as assigned
*Completes other duties as assigned.

*Participates in training and development activities to enhance own knowledge and skills
*Responsible for checking to ensure that the Insurance Verification Form is signed by patient/guardian prior to admission.
Responsible for communication with patient/families regarding insurance questions and/or concerns.
Responsible for communicating all insurance issues with Department Manager.

*Stays abreast of organization's programs and services.

*Supports facility internal and external customer service standard.
Participates in mandatory orientation and training philosophy.
Supports the organization's customer service philosophy

Compliance Statement
Employee performs within the prescribed limits of Tanner Health System's Ethics and Compliance program.
Is responsible to detect, observe, and report compliance variances to their immediate supervisor, the Compliance Officer, or the Hotline.


Education
Bachelor's Degree

Experience
No prior work experience required

Licenses & Certifications
*NONE REQUIRED

Supervision
*The clinician has limited supervisory duties but may instruct new employees on correct work routines according to hospital policy and procedure.


Qualifications
*Ability to concentrate on tasks and meet deadlines
*Ability to confidentially maintain all information
*Ability to deal with the public and individuals within the organization
*Basic data entry skills preferred; including experience using a computer
*Basic knowledge of and skills applying principles of abnormal psychology and mental health problems
*College level reading and comprehension, writing and mathematical skills.

*Familiarity with psychological, sociological and medical terminology's
*Organization and time management skills
*Skills in analyzing and evaluating information, problem solving skills, excellent oral communication skills , and legible handwriting.


Definitions
*Communicating with Insurance companies, other Tanner departments, and co workers about payment issues of patients.
Keeping organized up to date documentation on patients.
Under general direction, the Case Manager coordinates a multidisciplinary approach to organize and coordinate effective, efficient quality care.
The Case Manager ensures the availability of sufficient clinical and financial information to enable the health care team to function efficiently and effectively within the continuum of care and the continuum of resources.
The Case Manager identifies pertinent roles for, and encourages active participation of, the clinical, administrative and ancillary staff in the case management process.
The Case Manager serves as a liaison among all functions related to case management including Administration, Medical Staff, Nursing Service and Fiscal Services.


Contact With Others
Performance of job requires contact with others where team work is essential, requiring tact in order to obtain cooperation.
Contacts may be outside of the organization also.


Effect Of Error
Probable errors may be serious and involve losses such as improper costs, overpayment, waste of material, damage to equipment, and delay in processing work.
Effect usually confined within the organization.
Most of work not subject to direct verification or check.
Regularly works with some confidential data such as account, salaries, patient medical records, which if disclosed might have adverse internal or external effects.


Supervisory Responsibility
Manages a small department (up to 15); has full responsibility for quality and quantity of work, costs, methods, and personnel; performs supervisory functions without intermediate supervisors.
Manages a medium sized department of employees (15 to 40); has full responsibility for work, costs, methods, and personnel; usually has one or more intermediate supervisors.


Mental Demands
Work involves a variety of complex problems to be solved under general organization policies.
Ingenuity and judgment are required to review facts, plan work, estimate costs, and deal with factors not easily evaluated, interpret results, draw conclusions, and take or recommend action.
Solutions to problems often require coordination with other departments.


Physical Effort
Minor physical effort - Job requires person to stand and/or walk frequently.
Lifts, carries, or uses lightweight (1 to 25 lbs.)
materials or equipment less than half of the day.
Works in reaching or strained position intermittently.
Office or laboratory work requires close visual effort less than half of day.
Office or Laboratory work with concentration on a monotonous, repetitious procedure or skill most of day, where speed and accuracy are essential.


Working Conditions
Minor - Occasionally involved in exposure to dirt, odors, noise, or some work is performed with exposure to temperature/weather extremes/occupational risk and probability of coming into contact with blood borne pathogens, other potentially infectious diseases, or biomedical/bio-hazardous materials.


Physical Aspects

Continually (at least once per day)
*Typing
*Hearing
*Visual
*Speaking

Frequently (at least 3 times a week)
*Manual Dexterity ?
picking, pinching With fingers etc.

*Standing
*Walking

Occasionally (at least once a month)
*Bending
*Reaching ?
above shoulder
*Reaching ?
below shoulder
*Balancing
*Lifting up To 25 lbs.

*Carrying
*Kneeling
*Squatting
*Pushing/Pulling ?
up To 25 lbs.