Utilization Management & Appeals Outpatient Coordinator
Company: Catholic Health
Posted on: May 13, 2022
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
Specific Responsibilities And Duties
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
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
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
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
Coordinates Peer-to-Peer meetings between physicians and
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
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
Performs other related duties as assigned or requested.
Position Requirements And Qualifications
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
Keywords: Catholic Health, New Haven , Utilization Management & Appeals Outpatient Coordinator, Executive , Melville, Connecticut
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