Providence Health & Services Utilization Review Specialist in Kodiak, Alaska
Providence is calling a Utilization Review Specialist (Utilization Review, Day Shift, 0.6 FTE) to Providence Kodiak Island Medical Center in Kodiak, Alaska. We are a community of caregivers delivering every day on our Mission to provide compassionate care that is accessible for all - especially those who are poor and vulnerable.
In this position, you will:
Embraces the Providence Service Standards in all aspects of position. Presents and conducts self in a professional manner. Provides support to coworkers and customers while demonstrating service excellence by building positive interpersonal relations to ensure productive and positive relationships are maximized. Develops a deep understanding of customer’s perspectives and needs and works to meet their expectations. Builds a culture of true caring by behavior and interactions with others.
Communicates in a compassionate and professional manner. Demonstrates professional interpersonal and verbal skills when communicating with other department and of the care delivery team to provide optimal continuity of care to patients and their families. Is able to communicate effectively with a wide variety of people from differing literacy levels, languages and cultures. Demonstrates commitment to teamwork and interacts harmoniously with others to ensure team success. Supports new orientees in learning department routines.
Demonstrates effective priority setting and organization skills to promote departmental workflow and cost efficiency. Ensures smooth, efficient services and maximizes comfort and confidentiality for the patient. Anticipates potential obstacles and adjusts work assignments to prevent unnecessary delays. Recognizes errors/problems and takes corrective action when necessary. Utilizes available resources to recognize errors/problems and takes corrective action and assists with problem resolution.
Demonstrates knowledge and support of quality improvement goals. Participates in department, facility and organizational projects or committees as assigned.
Ensures verification of insurance eligibility. Identifies services and payers requiring authorization and ensures required authorizations are in place. Identifies services requiring referrals/consent forms and ensures they are signed and in place. Validates motor vehicle accident, workman’s compensation or other third party liability paperwork has been completed. Processes real time eligibility and assigned denial work queues timely and accurately. Maintains current knowledge of and competency with numerous Federal, State and other regulatory body compliance regulations and third-party insurance plans.
Assists with external review companies, agencies, and consultants, using advocacy and negotiating skills that address medical necessity and appropriateness of inpatient/outpatient levels of care. Assists department with tracking and managing length of stay, avoidable days, denials and appeals of inpatients/outpatients. Assists in obtaining required authorizations for inpatient admissions.
Uses multiple computer applications to establish accounts and obtain verification information. Maintains accurate, clear, concise, and complete account notes and other relevant information. Required to think independently and to identify and make complex decisions in a fast-paced environment.
Assists in decreasing liability risk factors for the institution by applying quality screens to medical records and analyzing data for potential risks. Communicates findings to department leader.
Assists the department in the appeals process upon receipt of a non-qualifying determination. Maintains communication channels with department leader, admissions staff, the patient account department and financial counselors. Uses established procedure to resolve denial-of-payment conflicts.
Consults, collaborates with, and values team members and other health professionals to plan and assure transfer of timely information, in order to meet patient and family needs in a seamless, safe, and effective process. Establishes and maintains relationships with community service providers to facilitate the plan of care and continuity of care. Identifies, resolves, and escalates major issues and service failures that impede success. Maintains confidentiality of all patient demographic, medical and financial information; ensuring proper handling and disposal of confidential documents and adherence to HIPPA.
As a team member, looks for ways to identify patient, process, system improvements, utilization usage, and readmissions prevention with the use of data analysis and collaboration skills. Participates in department case reviews, to promote competencies, problem solving, and patient management in meeting our patients’ medical and social needs, as well as the organization’s systems needs across the continuum.
Required qualifications for this position include:
High School diploma or equivalent
Basic Life Support (BLS) certification within 90 days of hire
Knowledge of medical terminology
1 year clinical experience/ hospital billing experience
Ability to work well with ill, disabled, elderly, and emotionally distressed patients/families
Preferred qualifications for this position include:
Associate’s degree in a clinical healthcare or business field
1 year of utilization review experience
Knowledge of CPT and ICD9 coding
Knowledge of State, Federal and other regulatory compliance regulations, including Medicare, EMTALA and ABN
About Kodiak Island Medical Center
Providence Kodiak Island Medical Center (PKIMC) provides comprehensive health care to residents and visitors of Kodiak Island. This critical access hospital features 25 acute care beds, including four birthing suites, one OB triage room, and two ICU beds. In addition, the Elder House, PKIMC’s long term care facility, has 22 beds.
PKIMC provides an extensive array of inpatient and outpatient services, including emergency department, surgery, laboratory services, maternity, general medicine, physical therapy, occupational therapy, respiratory therapy, sleep studies, specialty clinics, diagnostic imaging services and pharmacy and is staffed by a mix of primary care physicians, surgeons and specialists who provide family practice, internal medicine, obstetrics, radiology and general practice.
For more information regarding Providence Kodiak Island Medical Center, please click on the following link: http://providence-kodiakhealthcare.jobs/
We offer a full comprehensive range of benefits - see our website for details
As expressions of God’s healing love, witnessed through the ministry of Jesus, we are steadfast in serving all, especially those who are poor and vulnerable.
Providence Health & Services is a not-for-profit Catholic network of hospitals, care centers, health plans, physicians, clinics, home health care and services guided by a Mission of caring the Sisters of Providence began over 160 years ago. Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.
Job Category: Billing/Insurance
Req ID: 247190