What Does An Utilization Review Coordinator Do At Unitedhealth Group
* Respond to incoming provider faxes and calls Develop relationships within the provider community and health services team Resolve service inquiries which could include: Notification entry, Providers status of an existing notification and determining if notification is required, Complete notification wizard along with ICD* and CPT coding, and Research of provider concerns and issues Manage incoming calls from providers, managing requests for services from providers and Plan staff.* Organize work and develop strategies to adapt to constantly changing workload as evidenced by: Performing multiple administrative tasks while concurrently triaging phone calls and incoming faxes and Timely response to provider and care coordination team needs Document within the clinical documentation system administrative actions, follow-up and key attributes necessary to track member setting of care and reportable indices.* Responsible for the resolution of escalated calls that are received by the UR team.* Document Member/Provider responses and call outcomes in CareOne as appropriate.* Constantly meet established productivity, schedule adherence, and quality standards while maintaining good attendance
What Does An Utilization Review Coordinator Do At Phoenix House
* Complete assessments and pre-certifications * Complete utilization, discharge, and peer reviews * Initiate and resolve appeals* Ensure EMR is up to date and complete* Utilize ASAM criteria to identify and advocate for appropriate level of care placement * Develop and maintain effective relationships with stakeholders including current and prospective referral sources, insurers/pay sources, Phoenix House clinical and medical staff and management* Advocate on behalf of Phoenix House and its clients with insurers/pay sources and others regarding treatment protocols, medical necessity issues, and quality of care matters* Ensure that both effective utilization management and client experience standards are maintained* Train staff on insurance utilization review and authorization procedures, and other managed care concerns to ensure prompt and effective information-sharing and service documentation* Responsible for consistent and timely reporting on key business metrics
What Does An Utilization Review Coordinator Do At Sedgwick Claims Management Services
* Accesses, triages and assigns cases for utilization review (UR).* Responds to telephone inquiries proving accurate information and triage as necessary.* Enters demographics and UR information into claims or clinical management system maintains data integrity.* Obtains all necessary information required for utilization review processing from internal and external sources per policies and procedures.* Distributes incoming and outgoing correspondence, faxes and mail; uploads review documents into paperless system as necessary.* Supports other units as needed.* ADDITIONAL FUNCTIONS and RESPONSIBILITIES Performs other duties as assigned.* Supports the organization's quality program(s
What Does An Utilization Review Coordinator Do At UHS-Dover Behavioral
* Conduct admission reviews working with Assessment and Referral Services to stay abreast of admissions.* Conduct concurrent and extended stay reviews on appropriate day and/or specified time.* Prepare and submit appeals to third party payors, effectively coordinating collection of all pertinent data to support the hospital and patient s position.* Maintain and update logs of review and maintain other appropriate records of the Utilization Review department.* Stay abreast of applicable UR trends.* Communicate pertinent third party payors issues to doctor and treatment team.* Attend daily treatment team meetings to discuss acuity issues, third party payors needs and gather information for reviews.* Work independently in gathering information for reviews from the patient record, taking the initiative to seek information from members of the treatment team.* Understand and communicate insurance information to team members, including benefits and levels of care offered.* Perform internal utilization reviews as indicated.* Master s prepared in a behavioral health major or an actively licensed State of Delaware Registered Nurse.* Experience in UR preferred.* Associated topics: activity, after school, county, fws, group, instructor, leader, resident, vacation
What Does An Utilization Review Coordinator Do At Amerihealth Caritas
* Under the direction of the unit Supervisor, the Clinical Reviewer is responsible for completing medical necessity reviews.* Using clinical knowledge and nursing experience, the nurse reviews provider requests for inpatient and outpatient services, working closely with members and providers to collect all information necessary to perform a thorough medical necessity review.* It is within the nurse’s discretion to pend requests for additional information and/or request clarification.* The nurse will use his/her professional judgment to evaluate the request to ensure that appropriate services are approved and recognize care coordination opportunities and refer those cases as needed.* The nurse will apply medical health benefit policy and medical management guidelines to authorize services and appropriately identify and refer requests to the Medical Director when guidelines are not met.* The nurse will maintain current knowledge and understanding of the laws, regulations, and policies that pertain to the organizational unit’s business and uses clinical judgment in their application.* This position will be based in our Des Moines, Iowa office