Utilization Review Assistant

This position will assist in the coordination of all activities related to insurance authorizations process for the Patient Access Utilization Review (UR) department. Activities may consist of collaborating with various medical staff and Medical Center personnel, participating in non-clinical appeals process, obtaining status updates on all outstanding appeals, monitoring and tracking of all financial activities related to the UR team. Participates in quality management and continuous quality improvement activities. Perform all job duties and responsibilities in a courteous and customer-focused manner according to the Hurley Family Standards of Behavior.  Works under the direction of the Director of Patient Access or designee who reviews work for effectiveness and compliance with established standards, policies, and procedures.

1. Perform necessary authorization-related tasks in an accurate and timely manner. This includes utilization of the Epic EMR system efficiently and effectively and providing sufficient and clear documentation of all actions taken.
2. Assist in the initial authorization approval process by communicating with various payers and other internal Medical Center personnel and submitting pertinent documentation to the payers for approval consideration.
3. Assist in submitting concurrent and retrospective reviews to appropriate payers. This may require following up with physicians and other health care providers to review admissions and continued stays not meeting criteria.
4. Stay abreast of health care benefit inclusions and exclusions for all financial classes, benefit changes, review requirements, and other pertinent regulations influencing the Medical Center.
5. Assist with appeals of denied days by third-party reviewers throughout each stage of available reconsideration/appeal mechanisms.
6. Review charts for instances of over/under utilization of ancillary services to ensure optimum quality of care and maximum reimbursement.
7. Collaborate with the Patient Access/Registration, Medical Records, Billing teams, and other hospital areas to ensure post discharge completion of all information necessary to generate timely billing.
8. Assist in drafting letters to third-party review entities and medical staff members and working with the Utilization Review Coordinators for approval and finalization of such letters.
9. Assist in identification, development, and implementation of new procedures designed to increase operating efficiency.
10. Review level of care for patients (with UR Coordinators and medical staff approval) regarding inpatient, observation, and outpatient care and relate this information to the Revenue Cycle teams for billing purposes.
11. Maintain all primary assignments (based on financial goals assigned to the UR department). This consists of working on Discharge Not Billed (DNB), Claim Edits, and Stop Bill work queues or reports to accomplish timely accounts resolution.
12. Perform other related duties as required/assigned. Utilizes new improvements and/or technologies that relate to job assignment.

• Associate's degree in healthcare or related field required (Bachelor's degree preferred).
• Two (2) years of healthcare experience in authorizations, coding, patient registration, billing, or utilization review. 
• Knowledge of hospital patient care admission processes and third party payer utilization requirements.
• Strong background and knowledge of payer authorizations and referrals.
• Ability to communicate effectively in oral and written modes.
• Ability to interact courteously and effectively with all levels of the Medical Center staff, patients, medical staff, external agency representatives, and the public.   

NOTE: If the incumbent is skillfully prepared and actively pursuing a degree, they will be required to obtain minimally an Associate's degree within one (1) year of accepting the position.