Education and Experience
- Required: High school diploma or equivalent; Associate’s degree or certification in a healthcare-related field preferred.
- Preferred: Bachelor’s degree in healthcare administration, nursing, or a related field.
- 2+ years of experience in Utilization Review, case management, or a similar healthcare operations role.
Knowledge
- Knowledge of Utilization Review processes and payer requirements.
- Familiarity with healthcare systems, electronic medical records (EMR), and clinical documentation standards.
- Understanding of healthcare regulations, including Medicare and Medicaid guidelines.
Skills
- Strong organizational skills to manage multiple tasks and meet tight deadlines.
- Excellent written and verbal communication skills for professional interactions with clinical staff, payers, and clients.
- Proficiency in Microsoft Office Suite (Word, Excel, PowerPoint) and familiarity with UR-related software.
- Attention to detail to ensure the accuracy of documentation and review submissions.
- Ability to work independently while collaborating effectively within a remote team environment.
Work Context
- Remote work environment requiring consistent, reliable communication with team members and stakeholders.
- May involve occasional travel for team meetings or client-related events.
Primary Job Duties
The essential functions include, but are not limited to the following:
- Coordination: Manage and track the submission of clinical reviews to payers, ensuring deadlines and requirements are met.
- Payer Communication: Act as the primary liaison with payers to address and resolve any issues related to utilization reviews.
- Documentation: Ensure that clinical documentation and review requests are accurate, complete, and compliant with payer guidelines.
- Team Support: Collaborate with utilization nurses and other team members to ensure seamless operations.
- Compliance: Maintain knowledge of payer guidelines and healthcare regulations to ensure all activities meet compliance standards.
- Process Improvement: Identify and implement opportunities to streamline UR workflows and improve operational efficiency.
- Client Service: Provide exceptional service to clients by addressing inquiries, resolving issues, and ensuring satisfaction with UR operations.