Utilization

The Utilization Management Rep (UM Rep) is responsible for completing routine, frontline clerical duties and administrative work necessary to support the daily operations of the Utilization Review Department.

Overall, the primary purpose of the UM Rep is to support the mission of Utilization Review Department to ensure the delivery of high quality, cost-effective patient care and services that incorporate the patients' preferences and values and are compliant with regulatory standards.

This is a clerical support role and is not benefits eligible.

Major Responsibilities :

Manage incoming fax, phone, and portal communications or any other requests from internal and external customers pertaining to clinical requests, approvals, authorizations, and denials;

determine action required, and document all activities performed accurately and clearly in the designated database / area(s) of EHR.

• Communicate clinical needs, authorizations, and denials to the Utilization Review Nurses and Managers for follow up
• Verify insurance information provided by callers, fax, or Portal and send information to payers as requested, including discharge dates and disposition or clinical reviews / summaries prepared by UM RNs (if directed to do), while ensuring that all actions taken align / comply with the confidentiality and HIPAA compliance guidelines
• Follow up with payers to validate the authorization and confirm the days approved, and capture approved days in the EHR
• Enter data into database, spreadsheets, and perform analysis as directed. Provide efficient, courteous, and expert customer service to all internal and external callers.

Open, sort, and process incoming mail / correspondence directed to the Utilization Review. Maintain the department records and files.

• Ensure provider compliance with Patient Status Admit Order (PSAO) co-signatures across the hospital sites covered by centralized UM.
• Utilize standard reports / patient lists within the EHR to identify PSAO co-signature delinquencies and follow up with reminders / escalations to physicians to sign admission orders
• Follow the standard process to notify treating physician via perfect serve or other approved / designated methods of communication.
• Interact with Site and System Physician Advisors based on guidelines for escalation. Document all actions taken and status updates in the EHR.
• Maintain PSAO spreadsheet to track signature requests. Provide support and instruction to physicians to assist in the LOC order signature process.

Education / Experience Required :

Knowledge, Skills & Abilities Required :

Competent in advanced functions with Microsoft Outlook, Word, Power Point, Excel and complete basic reporting Type 55 words per minute Strong critical thinking and communication skills to problem solve, and interact with colleagues, physician and payers.

Ability to foster and maintain effective professional relationships, manage conflict while demonstrating Advocate Aurora's Behaviors of Excellence at all times Ability to be flexible and function well in a fast paced, continually changing environment.

Assume responsibility for self-development by seeking out opportunities for growth and be an active participant in department, site and system initiatives.

Comply with strict adherence to predetermined procedures and processes, safety, compliance and privacy / HIPAA guidelines.

License / Registration / Certification : N / A

Physical Requirements and Working Conditions :

N / A

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent.

Incumbent may be required to perform other related duties.

Last updated : 2024-06-03