Utilization Review Assistant

Description

Title: Utilization Review Assistant

Department: OPSC Utilization Mgmt MCH OP

Status: Full-time

Shift: Day

MemorialCare is a nonprofit integrated health system that includes four leading hospitals, award-winning medical groups – consisting of over 200 sites of care, and more than 2,000 physicians throughout Orange and Los Angeles Counties. We are committed to increasing access to patient-centric, affordable, and high-quality healthcare; your personal contributions are integral to MemorialCare's recognition as a market leader and innovator in value-based and other care models.

Across our family of medical centers, we support each one of our bright, talented employees in reaching the highest levels of professional development, contribution, collaboration, and accountability. Whatever your role and whatever expertise you bring, we are dedicated to helping you achieve your full potential in an environment of respect, innovation, and teamwork.

Position Summary

The Outpatient Utilization Review Assistant, using decision trees and standard work, is responsible for a broad range of utilization review support services to ensure efficient authorization coordination including registering patients, eligibility verification, scheduling patient visits, obtaining authorizations, preparing billing data through data entry in EMR and 3rd party billing systems, maintaining patient information through chart documentation in EMR, preparing required reports and providing other support as requested. The Outpatient URA is responsible for selecting appropriate chart documents to submit timely requests to government insurances, private health plans, medical groups and IPAs to secure authorizations and documents activities and authorizations per standard work. The Outpatient URA is able to navigate and understand payer portals for transmission of authorizations.

Essential Functions and Responsibilities of the Job

• Appropriate chart documents are chosen and transmitted per decision trees and standard work to submit for authorization requests.
• Provides clerical support services including triaging telephone calls, mailing and faxing correspondences and printing reports.
• Obtains initial patient demographics, including referring/ordering physician and third party/guarantor information and documents in EMR per standard work.
• Chart documentation is transmitted per department timeliness requirements.
• Documentation in the billing system of activities and authorizations is complete and timely.
• Duties performed meet department productivity requirements.
• Timely notification (prior to services rendered for elective admissions and within 24 hours and/or the next business day for urgent/emergency admissions) to all insurance/medical groups. Verify eligibility, obtain benefit plan information and secure authorization when necessary. Communication of authorization received is sent per standard work.
• Cross-train to cover front desk, scheduling and registration.
• Other duties as assigned.

Qualifications

Minimum Requirements

Qualifications/Work Experience:

• 2+ years medical office/UR Department/Admitting Central Auth Unit/medical group experience in utilization review, insurance contracts, multi-payer inpatient authorization systems and/or business office operations is required, or 2+ years experience as a Licensed Vocational Nurse.

Education/Licensure/Certification:

• AA Degree and/or healthcare related certificate course preferred.