Job Description

Sidney Regional Medical Center is searching for a Clinic Utilization Review Specialist to join our team. This is a full-time position supporting Sidney Regional Medical Center and patients. The position will be based at SRMC Pole Creek Crossing campus from 0800 to 1700 Monday-Friday.

Duties & Responsibilities:

• Provides excellent customer service to internal and external SRMC customers.
• Ensures that prior authorization requests are completed in a timely fashion to meet contractual requirements and ensures that all reviews are conducted using nationally recognized and evidence-based standards.
• Analyze insurance, governmental, and accrediting agency standards to determine criteria concerning medical justifications and treatment or procedures.
• Knowledgeable of criteria for Medicare, Medicaid, and private insurance coverage.
• Efficiently navigate insurance provider portals.
• Collaborate with nurses, physicians and ancillary staff to ensure all information/documentation is obtained to support authorization, level of care and/or medical appropriateness.
• Acts as a resource to other departments, leveraging expertise relative to the authorization and medical necessity process.
• Respond to common inquiries or complaints from patients or regulatory agencies and address them forward them to the appropriate person when necessary.
• Is proficient in retrieving patient data in Electronic Medical Record.
• Performs and maintains accurate documentation.
• Communicates effectively with medical providers, nursing staff, rehab team and social workers so the needs of the patients can be met.
• Assist director with identifying and completing process improvements for the facility that involves authorization activity.
• Perform non-clinical Case Manager duties in Acute Care when needed.
• Assist director when appropriate, in research to reduce denials and improve reimbursement.
• Employee is expected to be sufficiently knowledgeable about the legal aspects of his or her responsibilities and activities to be able to avoid inadvertent violation of State and Federal statutes and regulations & standards and refrain from knowingly participating in illegal activities or failing to meet affirmative legal duties. Employee shall report any suspected or known illegal activity
• Regular Attendance.
• Other duties as assigned by management.

Education, Experience, & Licensure

• Education: High school diploma or GED
• Experience: Clerical/medical and prior authorization experience is preferred.

Knowledge, Skills, & Abilities:

• Reliable and timely attendance
• Strong customer service skills, both in-person and over the phone
• Ability to multi-task and prioritize workload
• Strong team player
• Ability to keep information confidential and protect patient information

Sidney Regional Medical Center is an EEO Employer/Vet/Disabled

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