Utilization and Appeals CoordinatorFacility: CHS Services Location: Melville, NY Department: CHS Appeals Category: Administrative / Business Support Schedule: Full Time Shift: Day shift Hours: 9-5 PM ReqNum: 6047570
Position Summary: The Utilization and Appeals Coordinator will perform activities to help facilitate utilization management and appeals functions to include coordination of specific process and payment related activities.
- Prepares necessary documentation for utilization management and appeals processes, performs data management and coordinates communication between members of the UM and Appeals teams to ensure timely follow through.
- Reviews providers' requests for services and coordinates utilization/appeals management review.
- Assist Utilization and Appeals Manager in setting up communications with payors and/ or physicians as applicable.
- Maintains electronic database for statistical and educational reporting as well as workflow. Prepares daily, monthly, quarterly, annual or ad hoc reports reflecting accurate utilization data in a timely fashion.
- Monitors denials as well as all financial metrics associated with front-end review process.
- Collects data, prepares analysis, and oversees communication tools (i.e. spreadsheets) for governmental and non-governmental agencies.
- Reviews all cases received from Patient Access to verify that the insurance pre-certification/notification process has been completed in order to meet contractual obligations.
- Keeps abreast of current changes affecting Utilization and Appeals Management as applicable.
- Manages/follow-up on certification status/appeal status with the Manage Care Payors or regulatory agencies, as needed or requested.
- Manages physician advisor reports and assists with facilitating UM Committee reviews when applicable.
- Notifies Department Leadership of potential missed timeframes for submission and follow-up on responses and escalates cases as appropriate.
- Coordinates Peer-to-Peer meetings between physicians and payors.
- Serves as a liaison between patient account services, physicians, care coordinators, Utilization and Appeals Managers, physician advisors and facility departments.
- Develops/validates daily work lists for Utilization and Appeals Manager.
- Assist with all insurance and regulatory audits and provides information to supervisor related to inaccurate and/or missing documentation as applicable.
- Provides support for ongoing projects as required
- Meets productivity standards.
- Attends meetings as required and participates on committees as directed.
- Performs other related duties as assigned or requested.
- Bachelor's Degree required; Master's preferred
- Required to pursue ongoing education, certification and self-development to remain current with industry standards and business objectives related to Care Management as appropriate.
- Sound knowledge and skill in the use of personal computer and software for word processing, spreadsheet and database applications required. Experience with EPIC, Midas, Star and other hospital software as required.
- Ability to effectively communicate with all levels of hospital staff in a verbal and written manner; demonstrated ability to be organized and efficient in prioritizing and managing assignments with minimal oversight and direction.
- Demonstrates a courteous and professional demeanor, team spirit and the ability to work in a collaborative, effective manner.
- Ability to utilize critical thinking and apply sound clinical judgment and assessment skills for decision-making.
- Knowledge of Federal, State and PRO regulations preferred.
- Maintains knowledge of requirements by third party payers, regulatory agencies, and managed care entities concerning levels of care, continuity of benefits and medical necessity guidelines.
- Knowledge of managed care and the current standards and trends of patient care, best practices, management tools.