Utilization Review Specialist

Summary

In support of the Director and their area(s) of responsibility, the Utilization Review Specialist provides clerical and administrative support for UR departmental daily activities.

Education
Associate’s degree or equivalent in related field from two-year college or technical school. Bachelor’s degree in related field a plus.

Certification, Registration & Licensure
None required. 

Experience
Experience working in a hospital, insurance company, or medical office setting is preferred. Demonstrated ability to effectively and positively interact with a multidisciplinary staff, patients and others. Demonstrated ability to perform as a member of a team. Knowledge of medical terminology and skills in multi-tasking, critical thinking and problem solving. Proficient in Microsoft Office applications, Cerner. Knowledge of revenue cycle is a plus.

Responsibilities

• Process all incoming electronic faxes from payers that include approvals, denials, and requests for clinical information. Requires the ability to review, accurately interpret, and disseminate faxes to the appropriate UR nurse, physician advisor, appeals nurse, etc.

• Coordinates all peer-to-peer meetings with insurance payers.

• Maintains schedule for Physician Advisors and communicates all meetings/activities with the Physician Advisor.

• Assist with appeals and denial clerical processes as directed.

• Creates and maintains databases/dashboards, filing systems, documents and data for department specific processes and protocols.

• Assists with preparation and updating of utilization review related reports, presentation material, as required.

• Participates in, and supports assigned department and hospital meetings, committees and functions.

• Provide overall administrative support for UR clinical leader, UR team, and Physician Advisors.

• Performs job specific competencies and other duties as assigned including providing back up coverage for care management administrative assistant.

• Ensure compliance with relevant regulations and guidelines related utilization review, such as those with CMS, DNV and others.

Concord Hospital is an Equal Employment Opportunity employer. It is our policy to provide equal opportunity to all employees and applicants and to prohibit any discrimination because of race, color, religion, sex, sexual orientation, gender, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status.

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Applicants to and employees of this company are protected under federal law from discrimination on several bases. Follow the link above to find out more.

If you are an individual with a disability and require a reasonable accommodation to complete any part of the application process, you may contact Human Resources at 603-230-7269.

The physical demands and characteristics of the work environment described here are representative of those that will be encountered by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to

perform the essential functions. The Dictionary of Occupational Titles Material Handling Classification is SEDENTARY. The employee must regularly lift, carry or push/pull less than 10 pounds, infrequently

lift, carry or push/pull less than 10 pounds, and occasionally lift, carry or push/pull up to 10 pounds.

While performing the duties of this job, the employee is regularly required to do fine motor, do repetitive motion, hear, and sit. The employee is frequently required to speak, and walk. The employee is occasionally required to bend, reach, squat, and stand. Specific vision abilities required by this job include color vision, depth perception, far vision, near vision, and peripheral vision. The employee is occasionally exposed to airborne pathogens, and slippery surfaces. The noise level in the work environment is usually quiet.