What are the responsibilities and job description for the Utilization Review Representative position at Humboldt General Hospital?
POSITION SUMMARY
(General statement reflecting the overall purpose of the position)
The position is non-RN. Under general supervision, the Utilization Review Representative conducts utilization reviews to determine if patients are receiving care appropriate to illness or condition. Review treatment plans and status of approvals from insurers. Collects and compiles data as required and according to applicable policies and regulations. Consults with nurses and physicians as needed. Gains exposure to some of the complex tasks within the job function. Visits with patients as needed to facilitate methods of insurance and payment options, including Obstetrics. Works closely with Case Management to ensure correct orders are entered for timely and correct billing. Initiate pre-certification and continued stay authorization. Maintain daily census and confirms insurance coverage of each patient. Obtain prior authorization for in house surgery requests. Verify orders, authorization and benefits for all other surgery being performed in house.
TASK LETTER CODE
PRIMARY DUTIES
(Are the essential job tasks or primary responsibilities that the individual who holds the position mist be able to
perform unaided or with the assistance of an accommodation. For example: DO (action verb) WHAT (object) Collects vitals from patients at the being of the visit according to clinic protocol.
% OF TIME PERFORMING DUTY
A
Must demonstrate ability to tactfully handle difficult situations with patients, families and physicians; excellent problem solving and critical thinking skills
B
Must portray a positive, courteous and professional manner to patients, families, visitors, co-workers and physicians, having excellent communication skills, customer service and privacy etiquette
C
Must maintain strict confidentiality of patient information, ensuring accuracy and quality of work produced
D
Analyze insurance coverage and benefits for service to ensure timely reimbursement
E
Facilitate payment sources for uninsured patients. Determine if patient's condition is the result of an accident and perform complete research to determine the appropriate source of liability/payment.
F
Admit, register and pre-register patients with accurate patient demographic and financial data
G
Explain payment and billing processes according to HGH credit and collection policies and implement appropriate collection actions and assist financially responsible persons in arranging payment.
H
Make referral for financial counseling, presumptive eligibility and charity. Determine necessity of third-party sponsorship and process patients in accordance with policy and procedure
I
Obtain authorizations based on insurance plan contracts and guidelines, or other payers
J
Enter and update referrals as required. Communicate with carriers regarding clinical information requested and to resolve issues relating to coverage and payment for all patient statuses
K
Generate, explain, and endorse the collection of patient balances, including copayments, coinsurances and deductibles, as well as any former or current balances outstanding.
L
Selected positions will be responsible for pre-authorizations, insurance verification, counseling and compliance questions for all payers, whether inpatients, outpatients, ambulatory
M
Assists in information for transfers/discharges and readmits to acute, ambulatory or specialty units as directed, including LTC and ER
N
Understanding and compliance with HIPAA, HITECH, Red Flag and other Privacy and CMS Regulations
O
Other related duties as assigned.
POSITION QUALIFICATIONS
MINIMUM EDUCATION: High school diploma or equivalent
PREFERRED EDUCATION:
MINIMUM EXPERIENCE: Two years receptionist/cashier or other related experience/business school training; Hospital, Medical, Office, Billing, Admitting and computer experience preferred.
REQUIRED CERTIFICATIONS: N/A
PREFERRED CERTIFICATIONS/LICENSES: CHAA (Certified Healthcare Access Associate)
KNOWLEDGE AND SKILLS NEEDED:
Knowledge of insurance coverage and billing Knowledge of medical terminology
Computer literacy and ability to effectively learn new software programs required Skill in oral and written communication, including reading comprehension
Skill in data analysis to gather and update statistics, logs, records and reports Ability to type quickly and accurately
Excellent customer service techniques Ability to multi-task and prioritize
SUPERVISES: N/A
PHYSICIAL DEMANDS: For physical demands and working conditions, see next page.
