Utilization Review - Business Support Specialist

Job ID: J135283
Company: West Penn Allegheny Health System
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: Dec 7, 2018

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Description

GENERAL OVERVIEW:

This position is responsible for covering vast roles within the Utilization Review management team that include managing bill processing, downgrades, entry into the system including reg, insurance verification, authorization, and financial counseling/management, and working in tandem with RN to ensure all patients coming into the health system through transfers/direct admissions/ED have appropriate documentation ensuring expediting of claim and authorization for RN when insurance companies accept clinical review.

ESSENTIAL RESPONSIBILITIES:

  • Ensures accurate and complete documentation and information on all transfers and admissions into AHN for appropriate order writing and level of care upon entry into the system (with RN support). (45%)
  • Implements and organizes downgrades compliantly and per documentation. (10%)
  • Investigates concerns for improper billing/coding practices and recommends corrective action, works collaboratively to understand denial/appeal management process and alert edits/rejections. (10%)
  • Identifies trends with claim holds and denials and provides communication to all necessary parties. (10%)
  • Communicates with all parties in a professional manner to alert of specific problem issues. (10%)
  • Ensures confidentiality of all patient accounts by following HIPAA guidelines. (5%)
  • Proficient with department software, analytical tools, basic coding and billing knowledge, and revenue cycle operational policies. (5%)
  • Performs other duties as assigned or required. (5%)

QUALIFICATIONS:

Minimum

  • Bachelor's degree in health care related field or three years' experience in healthcare environment or related field with exposure to healthcare coding, billing, reimbursement, registration, insurance verification

Preferred

  • 1 year experience with medical necessity appeals
  • Competency of inpatient and outpatient coding guidelines

Summary

This position is responsible for covering vast roles within the Utilization Review management team that include managing bill processing, downgrades, entry into the system including reg, insurance verification, authorization, and financial counseling/management, and working in tandem with RN to ensure all patients coming into the health system through transfers/direct admissions/ED have appropriate documentation ensuring expediting of claim and authorization for RN when insurance companies accept clinical review.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf)
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For accommodation requests, please call HR Services at 844-242-HR4U or visit HR Services Online at HRServices@highmarkhealth.org

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