Utilization Management Administrative Coordinator

UnityPoint Health Information

Under the guidance and supervision of the Manager of Utilization Management and RN UM Specialists, the Administrative Coordinator serves a key role in supporting the affiliate-level Utilization Management and denials processes by coordinating incoming requests for information from multiple payer sources. While the role is multifaceted, the primary focus relates to financial risk mitigation and regulatory compliance.

The Coordinator will conduct maintenance and utilization of EPIC work queues that support obtaining authorization for patient stays. The Coordinator communicates with payers via telephone, fax, or email, and is responsible for ensuring clinical requests are sent in a timely manner and in a thorough fashion. The Coordinator is expected to acquire an understanding of third party authorizations, verification, and denials, and proceeds with notification/documentation to appropriate parties. Coordinator is also responsible for clerical/administrative support to Utilization Management nurses as assigned.

Utilization Management Insurance Coordination

• Coordinates and serves as primary point of contact for affiliate-level Utilization Management (UM) inquiries & requests for information from internal and external sources. Receives and documents UM requests including researching to determine appropriate action needed to complete request according to established processes. Seeks necessary clinical direction of RN UM Specialist staff or Manager.
• Coordinates appropriate and timely exchange of information with payers, UM nurses, Financial Clearance Team, and/or other internal users. Maintains current knowledgebase of payer requirements and contact information
• Monitors and follows up on requests as needed to ensure accurate, timely completion in accordance with payer guidelines/request specifics. Provides information as requested in a proactive, timely manner
• Monitors and completes accounts on multiple work queues in EPIC, including referrals and denials.
• Monitors requests in work queue for clinical information. Prepares/faxes requested documentation for review to third party payers. Ensures receipt of documents. Documents sending of clinical information in patient chart in EPIC.
• Collects data on volumes, sources and types of requests
• Performs basic data analysis as requested
• Suggests process changes to improve accuracy and timeliness
• Identifies issues and seeks direction from Manager and/or RN UM Specialist as needed

Denial Request Coordination

• Serves as primary point of contact for affiliate-level denial inquiries from internal and external sources under direction of the Manager.
• Coordinates and logs incoming affiliate-level denial requests. This includes performing research to determine appropriate action needed to complete request according to established processes.
• Maintains current knowledge of payer requirements and contact information.
• Coordinates denials with outside organizations used for Second Level Review (e.g. AppriseMD).
• Monitors and follows up on all requests to ensure timely completion.
• Monitor/document third party payers approved days, denials, requests for further information.
• In coordination with RN Utilization Management Specialist, communicate opportunities for Peer to Peer from third party payers, with our physicians. Coordinate discussions between payer physician and UPH physician, as indicated. Document requests/results of Peer to Peer conversation.
• Monitors and follows up on all P2P requests to ensure timely completion.
• Collects and inputs data on P2P requests into designated database.
• Maintains Denials Databases in an accurate and timely manner to support data analysis and reporting.

Administrative / Clerical Support

• Answers telephones for assigned affiliates: Screens calls and callers, referring them to appropriate person/department in timely manner as requested.
• Responds to fax requests in timely manner as requested.
• Maintains designated filing and record keeping systems. Assists with preparation of reports, graphs, and statistical information as requested.
• Maintains confidential files as requested.
• Serves as a secretary at department staff meetings as directed, including attending/producing meetings and maintain minutes as requested.
• Orders supplies as needed as requested.
• Assists with maintaining schedule as requested.
• Performs other related administrative, clerical, and secretarial functions as requested.

Education:

• Associates degree or above in related field or 2 years direct and applicable work experience

Experience:

• Patient care experience/knowledge
• Customer Service or Administrative Support
• Written & verbal communication proficiency

Licenses/Certifications:

• Valid driver’s license when driving any vehicle for work-related reasons.

Knowledge/Skills/Abilities:

• Microsoft Office proficiency (Outlook, Word, Excel)
• Customer/patient focused
• Ability to work with minimal supervision
• Ability to manage priorities/deadlines
• Excellent verbal and written communication skills
• Ability to multi-task and prioritize workload
• Flexible and adaptable to changing environment
• Excellent critical thinking and problem solving skills
• Positive attitude with team-oriented approach