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Utilization Management Assistant
Job Description
Performs notification to payors for inpatient/observation/outpatient in a bed elective status non-elective admissions to Sarah Bush Lincoln Health Center and verifies eligibility documented per the registration clerk. Notifications must be made within 24 hours of the admission or for admissions occurring during a weekend or holiday, by the end of the first working day thereafter. Failure to notify payors may result in denial or delay in payment of claims. Supports Utilization Review RNs in submission of clinical data to payors as required. The UR facilitator manages a diverse workload in a rapidly-changing regulatory environment including notification post discharge to patients regarding any change in patient status.
Responsibilities
Assists UR Committee and UM activity
a. Assists with preparation of Physician Advisor Peer-to-Peer appeals and appeal letters for denials.
b. Other audit activities as requested., Collaborates with the registration clerks, the coders and other staff to assure correctness of patient information., Collaborate with the Utilization Review RN team to provide accurate and complete clinical information in order to obtain authorization of inpatient/observation status., Completes short stay work queue reviews within 5 business days, or earlier as directed by UM Director., Demonstrates a working knowledge of approved status determination criteria., Demonstrates a working knowledge of regulatory and survey standards (Medicare, Medicaid and Joint Commission), Documents in patient chart and emails pertinent information to appropriate departments, Escalates UM issues to the Director, Physician Advisors and utilization review RNs in a timely manner and monitors the issue until it is resolved., Identify payors requiring notification of hospital admission status, Investigates disputed medical claims., Manages Medicare Part B notices to Medicare patients by certified mail., Notifies all appropriate departments and staff of pertinent issues (heart caths, audit findings, Behavioral Health requests and EQ notices)., Notifies payors of patient admission, Obtains diagnosis codes and confirms eligibility, Reflects concise clinical pertinence in documentation throughout EMR., Request diagnosis and procedure codes from the Coding department for patients located on the admission list each day. Categorize them according to payor requirements for notification, Responds to telephone and written inquiries from clients, providers, payors, regulatory agency's, and departments throughout the healthcare system, communicating information received to appropriate staff in a timely and efficient manner., Responsible for ensuring that appropriate data is tracked, evaluated and reported., Scans all pertinent hard copies of approvals and denials into the EMR and documents same., Serves as a facilitator for utilization review RNs and others to ensure consistent and accurate patient status determination for appropriate claim submission., Supports review of operating room schedules, The following elements are necessary for accurate and timely processing of an inpatient admission notification:
• Member name & ID number
• Member date of birth (DOB), address and phone number
• Admission date – if discharged provide discharge date and disposition
• Facility name & National Provider Identifier (NPI)
• Admitting physician (first & last name) & National Provider Identifier (NPI)
• Admitting diagnosis and/or ICD-10 code
• Admission source (emergency, elective, etc.) and admission type (medical, surgical, etc.)
• Contact name & phone/fax number (for additional information if needed)
Requirements
Associate's Degree, High School (Required)
Compensation
Estimated Compensation Range
$18.68 - $28.95
Pay based on experience
