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Utilization Review Tech

KPC Global MSO

Santa Ana, CA

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JOB DETAILS
SKILLS
Accounts Receivable, Administrative Skills, Billing, Blood-Borne Pathogens, Communication Skills, Computer Skills, Content Management Systems (CMS), Current Procedural Terminology (CPT), Data Collection, Data Entry, Data Management, Detail Oriented, Documentation Plan, Fax Machines, HIPAA (Health Insurance Portability and Accountability Act), Health Insurance, Health Plan, Healthcare, Healthcare Providers, Healthcare Software, High School Diploma, Hospital, ICD-10, Insurance, Insurance Documentation, Leadership, Licensed Practical Nurse/Licensed Vocational Nurse, Lift/Move 25 Pounds, Mail Processing, Manual Dexterity, Medical Records, Medical Terminology, Microsoft Excel, Microsoft Office, Microsoft Outlook, Microsoft Word, National Committee for Quality Assurance (NCQA), OSHA, Organizational Skills, Pathogens, Patient Care Denials, Patient Charts, Patient Confidentiality, Physical Demands, Presentation/Verbal Skills, Regulations, Regulatory Compliance, Reimbursement, Software Administration, State Laws and Regulations, Time Management, Treatment Plan, Utilization Management, Utilization Review Accreditation Commission (URAC), Writing Skills
LOCATION
Santa Ana, CA
POSTED
1 day ago
SUMMARY

Under direction of the Utilization Review Technician Supervisor, the Utilization Review Technician coordinates with the Utilization Management Department while being responsible for coordinating phone calls, clinical requests, upkeeps data entry, organizes denials and mailing/faxing appeals, tracking data from various insurance providers and health plans regarding authorization and/or denials, expedite reviews and documentation to insurance providers. Monitors patient charts and records to provide to responsible parties and request for authorization for hospital admission. Reviews treatment plans and status of approvals from insurers. Collects and compiles data as required and according to applicable policies and regulations. Performs administrative duties for the Utilization Management Department, and directed in several aspects of duties. Position is non-RN/LVN.

REQUIREMENTS

  • Ability to establish and maintain effective working relationships across the Health System
  • Ability to interpret and understand various medical insurance plans and make accurate determinations regarding coverage
  • Follow up with insurance companies regarding the status of outstanding claims and necessary steps for resolution
  • Answer and review pertinent insurance correspondence to ensure complete and accurate reimbursement for medical claims
  • Responsible for working payer correspondence, edits and aged account receivable, and identifying and correcting billing errors
  • Pull daily reports utilizing Microsoft Excel and providing correct correspondence to payer
  • Research payer rules and regulations to maintain current payer knowledge
  • Comply with HIPAA and other compliance requirements to protect patient confidentiality
  • Manage data in internal and external databases with accuracy
  • Provide high-level administrative support and assistance to the Director and Supervisor or other assigned leadership staff
  • Perform clerical and administrative tasks including drafting letters, memos, invoices, reports, and other documents for senior staff
  • Prepare patient charts for medical audits
EDUCATION & EXPERIENCE REQUIREMENTS:
  • High School Diploma
  • Healthcare experience strongly preferred
SKILLS & ABILITIES REQUIREMENTS:
  • Excellent verbal and written communication skills
  • Excellent organizational skills and attention to detail
  • Excellent time management skills with a proven ability to meet deadlines
  • Ability to function well in a high-paced and at times stressful environment
  • Extensive knowledge of office administration, clerical procedures, and recordkeeping systems
  • Able to type minimum of 50 words per minute
  • Knowledge of CMS, State Regulations, URAC and NCQA guidelines preferred.
  • ICD-10 and CPT coding experience a plus
  • Experienced computer skills with Microsoft Word, Microsoft Outlook, Excel and experience working in a health plan medical management documentation system a plus
  • Extremely proficient with Microsoft Office Suite or similar software with the ability to learn new or updated software
  • Medical Terminology preferred
PHYSICAL REQUIREMENTS:
  • Body Positions: Sitting and standing for prolonged periods.
  • Body Movements: Arm and hand dexterity.
  • Body Senses: Must have command of close and distant sight, color perception and hearing.
  • Strength: Ability to lift and move up to 25-pounds.
Working Environment:
  • Work in an office, where the climate is controlled.
  • OSHA exposure category: II
  1. Category I - Position includes tasks that involve exposure to Blood borne Pathogens.
  2. Category II - Position includes tasks that do not have exposure to Bloodborne Pathogens, however employment may require unplanned Category I tasks.
  3. Category III - Positions includes tasks that do not involve exposure to Bloodborne Pathogens. This position would not be required to perform Category I tasks.

About the Company

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KPC Global MSO