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Utilization/Authorization Specialist

Lawrence, MA

Department
Utilization Review
Job ID
9874
Schedule
Full Time
Shift
Days

Description

Are you looking for an interesting and dynamic position in the growing field of home health care?  

The Utilization Authorization Specialist assists with the coordination of managed care patients: follows procedures to obtain needed authorizations, documents necessary authorization/utilization information in patient electronic medical record, tracks appropriate utilization of services and has knowledge of reimbursement guidelines.

Responsibilities:

  • Obtain authorization for assigned managed care insurance programs for visits requested by clinicians.
  • Enters all authorized visits in the UR log along with the date, frequencies, ranges, disciplines, case manager’s name and telephone number.
  • Collaborate with the billing and referral departments to facilitate the many different processes required for managed care and billing.
  • Refer complex cases to UR nurse for review. Is willing to coordinate and participate in case conferences as requested.
  • Review initial admission information to provide required clinical documentation to providers for authorization, utilization and payment.
  • Continually provides managed care organizations with clinical documentation to comply with the payers’ requirements to obtain reimbursement.
  • Alert clinicians and managers regarding need for additional authorization or delays in discharges.
  • Facilitates the timely transfer of the universal health care form to all managed care insurers.
  • Follows through in a timely manner to request/obtain service authorizations per the insurance defined procedures.
  • Enters all relevant email and voice mail messages received on to the UR log daily.
  • Keeps the UR Manager informed of any problems, changes and trends of any managed care process changes.
  • Continuously assess the clinical data to make sure the visits are medically necessary and meets managed care criteria (skilled, homebound, MD orders and reasonable).
  • Advocate for the patient to ensure quality outcomes and the delivery of appropriate clinical services.
  • Acts as a resource to all staff members, referral, and billing and outside providers to insure appropriate utilization.
  • Maintain knowledge of federal, state, JCAHO and managed care regulations as well as agency policies and procedures.
  • Foster a friendly, helpful atmosphere for clinical, billing and referral departments.
  • Communicate with staff regarding insurer requests for additional documentation.
  • Demonstrates knowledge of the CQI process.
  • Demonstrates a knowledge and understanding of what to report to the supervisor or Director of Quality Improvement when concerns of corporate compliance arise.
  • Ensures compliance within guidelines set forth by regulatory agencies (JCAHO, DPH, ERISA etc.) and demonstrates compliance with Home Health Foundation policies and procedures.

Qualifications:

  • Knowledge of insurance authorization/utilization process.
  • Exceptional documentation, communication and organizational skills.
  • Insurance verification experience a plus.
  • Associate’s Degree Preferred.
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