Description

Under the supervision of the Utilization Review Manager, the Utilization Review Assistant provides support to ensure that all utilization management documentation and information requirements, including electronic communication, are met. Work areas include payer notification, authorization management, denial management, escalations, and communication and coordination between the payer, Business Office, and UR Team.

Core Competencies

Acts as a liaison for the department, fostering clear communication and collaboration with other hospital departments, physicians, office staff, and other relevant stakeholders. Composes list of resources for Case Managers and Social Workers as needed. Confers with assigned nurse regarding need for any additional hospital services or referrals and assists with referral process, if needed. Coordinates department statistics and forwards information to budget department and director. Delivers daily the QI0 2nd letter to MCARE patients 48 hours prior to DC for compliance with the CMS. Ensures payer communication with reference #s and authorizations for benefits coverage for any outside services including MCARE. Reports errors, knowing that Torrance Memorial engages in a positive environment for the correction of errors (Non-punitive) Works collaboratively with other departments and teams (i.e. Physician Advisor, Case Management, Business Office, Patient Access, Physician Offices, etc.) to mitigate potential denials. Ensures completion of timely and accurate payer and repatriation documentation, retrospective review requests, WQM management, and post-stabilization documentation. Responds to audit requests timely and escalates to the appropriate team for review and response (HIM, Risk Management, Physician Advisors, Leadership, etc.)