You Make Us Grow. You Make Us Sharp.

Hours:

Shift Start Time:

Variable

Shift End Time:

Variable

AWS Hours Requirement:

8/40 - 8 Hour Shift

Additional Shift Information:

Weekend Requirements:

As Needed

On-Call Required:

No

Hourly Pay Range (Minimum - Midpoint - Maximum):

$28.170 - $35.210 - $39.430

The stated pay scale reflects the range that Sharp reasonably expects to pay for this position.  The actual pay rate and pay grade for this position will be dependent on a variety of factors, including an applicant’s years of experience, unique skills and abilities, education, alignment with similar internal candidates, marketplace factors, other requirements for the position, and employer business practices.

What You Will Do
This position supports the system centralized utilization management department to meet division and organizational objectives, facilitate effective communication between department staff and the internal and external customers to the department, including but not limited to the business office, revenue cycle, physicians and payers. This position is accountable to ensure timely follow up on payer requests for clinical documentation, optimal inbound and outbound fax management to mitigate denials and ensure established timeliness response metrics are met, and reconciliation of hospital authorizations. Identification and escalation of concerns to the ICM System Centralized Utilization Management team to mitigate denials. Assists in capturing administrative days under the direction of the UM CM's. A key member of the UM customer service team to meet and exceed the customer's expectations.

Required Qualifications

• H.S. Diploma or Equivalent

Preferred Qualifications

• Other Health related education.
• Other Successful completion of Medical Assistant Program or equivalent.
• 2 Years hospital experience.
• 2 Years Medi-Cal experience.

Essential Functions

• Monitor Utilization Management Queues
  
  Works with the other members of the UM team to monitor timely management of the UM queues. Escalates to management when queues are outside of established turnaround timeframes.
  Verifies current insurance plan eligibility. Assists the UM CM’s to report inaccurate insurance information on the facesheet.
  Reviews patient list and prioritizes/plans for the day.
  Contributes to the continuous improvement initiatives of the system centralized utilization management team to deliver quality interventions in a timely manner.
  Maintains proactive communications with insurance representatives, UM CM’s and TP CM teams at the site level.
  Maintains a current payer contact list to support utilization management activities.
  Maintains passwords and access to payer portals to ensure timely UM authorization capture.
• Teamwork and Collaboration
  Acts as facilitator between payors and UM team members.
  Ensures UM team members are updated daily and thought out the day as needed.
  Keeps the ICM UM Leadership aware of inability to complete assigned duties or tasks.
  Responsible for timely and accurate retrieval and appropriate action on departmental phone messages and necessary fax
  communication.
  Work closely with revenue cycle to ensure the latest reimbursement and contract information is available to the utilization managers.
  Work closely with the revenue cycle to make sure all are aware of denials real time.
  Supports staff and leadership to meet department objectives.
• Database Management
  Assists with the processing of letters of authorization, appeal or denial.
  Prepare databases and written reports for leads, manager, and director in a timely manner as requested and within the scope of work.
  Initiates and participates in the creation and development of forms and lists.
  Assist UM case managers and physician advisors with denial cases, setting up peer to peer reviews as needed.
  Must demonstrate attention to detail and accuracy.
• Department Operations
  Ensures UM staff have appropriate resources and information to expedite smooth transition to through continuum
  and optimize third party payer reimbursement.
  Monitor authorization for all patients in-house to ensure reimbursement and payment for correct level of care.
  Monitor completion of retro reviews and notifies lead of reviews pending by noon the second business day of the request.
  Provide needed documentation for Medi-Cal TAR free process, and complete TARs timely for those patients who are not
  appropriate for the TAR free process.
  Attends department meetings.
  Initiates and participates in huddles and quality improvement activities.
  All work is consistently completed on time and in a timely manner.
• Authorization Reconciliation
  Confirm discharges from previous day and ensure that authorizations or denials are captured and documented.
  Documents activities as per the departmental processes and with the electronic medical record.
• Industry Skills and Competency
  Obtain detailed benefit coverage for complex requests specific to patient plan coverage.
  Investigate and follow-up on all eligibility issues in accordance with hospital guidelines.
  Performs review of all prior authorizations, entering into the electronic medical record.
  Researches and assists in the denial process-gathers documentation for the UR lead, director, and attending physician.
• SCMG UMRC Specific
  Obtain detailed benefit coverage for the more complex requests for service specific to member plan coverage.
  Apply the principles of SCMG guidelines and Health Plan benefit guidelines to approve referrals designated at the CRC level.
  Investigate and follow-up on all eligibility issues in accordance with health plan and SCMG guidelines.
  Process referrals for prior authorization.
  Coordinate, review and process the more complex referrals for prior authorization for medical care and services, including emergency room, inpatient admission, durable medical equipment, home care and other miscellaneous services for the efficient and effective delivery of inpatient services.
  Performs review of all prior authorization referrals. (Responsible for all levels of the referral from generation, approval and acquisition).
  Obtains necessary medical information for use by themselves, Medical Directors, the Hospitalist Physician and/or Case Manager.
  Identifies and refer requests for review by higher level staff (Medical Director, Hospitalist or HCM) within department turn around time (TAT) standards.
  Research and assist in the denial process - gathers documentation after review by medical director, ensure packet information is complete, assesses and select the appropriate denial reason. Maintain mandated TAT for denials.
  Obtains and gathers clinical information from multiple sources including use of Sharp and/or Hospital applications to retrieve patient medical records for review by Hospitalist Case Managers, SNF's or outpatient service providers.
  Verifies and documents eligibility and benefit details.
  Obtains prior authorizations for specific medications, through SCMG Pharmacy or through the patient's health plan when applicable. Has all information available to help with the review process.
  Informs and distributes health plan criteria to the Medical Director, CM or themselves to make a determination regarding an authorization for service or equipment.
  Updates inpatient IDX referrals with correct diagnoses, bed type and disposition.
  Generates or assist in the dissemination of Case Management Referrals.
  Generate informational referrals for patients that are accepted to hospice while admitted as inpatient.
  Research and interpret all ICD-10, CPT and HCPC coding using appropriate tools.
  Make determination on the more complex claims that are designated CC authorization level within SCMG TAT guidelines.
  Coordinates, reviews and processes more complex retrospective claims for medical care and services, including, SNF inpatient admission, medical transportation, durable medical equipment and other miscellaneous services for the efficient and effective facilitation of claim adjudication.
  Tracks and informs identified personnel of expired patients.
• Professional Development
  Actively identifies gaps in skills and competencies and participated in seminars/classes to enhance gaps.
  Attends and actively participates in department/team process/quality improvement activities.
  Actively participates in all-staff meetings and stand-ups.

Knowledge, Skills, and Abilities

• Bilingual preferred.
• Knowledge of hospital payors preferred.
• General filing knowledge.
• Demonstrated proficiency in Microsoft Word, Microsoft Excel, Microsoft Outlook, and other software programs.Excellent organization, managerial and time management skills with the ability to multi-task.
• Excellent analytical, problem solving and supervisory skills, knowledgeable of medical terminology, and current standards of clinical practice, professional counseling, mentorship and resource allocation.
• Knowledgeable in the use of ICD-10, CPT4, and HCPC coding systems.
• Proficient in typing and computer data entry (45 wpm).
• Excellent verbal and written communication skills.
• Ability to read, speak, and hear English clearly.
• Able to work independently in research and decision making with minimal direction from higher level of staff.

Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected class

Other; Other; H.S. Diploma or Equivalent