Experience Inc. Jobs

Employment Type:

Full time

Shift:

Day Shift

Description:

The Appeals and Utilization Management Coordinator under direction and in collaboration with the RN Care Coordination Manager, provides support to the utilization management, denials and appeals process for the THMA South hospitals. The Appeals and Utilization Management Coordinator ensures the delivery of effective and efficient patient care as it relates to proper processing and accuracy of patient stay claims data, denials management, and appeals. Assists RN Manager with establishing tools, processes, policies, procedure, and systems to optimize program effectiveness. Collaborates with RN Manager to provide support to the Emergency Department Case Manager, Utilization RNs, and Utilization Management support staff. Also adheres to the utilization management, denials and appeals processes to ensure compliance with CMS regulations, Joint Commission, and payer contracts. Assists in developing tools, processes and systems to optimize program effectiveness.

• Maintains primary ownership/responsibility for Pennsylvania state Medicaid patient case reviews in accordance with state guidelines

• Ensures timely review of appeals including case preparation with all relevant documentation, scheduling and processing the review to be conducted by the Physician Advisor to ensure all deadlines are met

• Collaborates with Physician Advisor to clarify medical necessity or clinical rationale

• Assists in corresponding and communicating with external managed care (IBC, Aetna, etc.) and regulatory organizations (Medicare, Medicaid, etc.) when necessary

• Ensures appropriate flow of information for RAC requests

• Ensures timely review of all clinical denials issued by third party payors

• Ensures all documentation associated with process and handling of administrative denials is accurate, consistent and complies with regulatory standards, monitors payor correspondence and tracks and processes appeal outcomes to resolution

• Ensures documentation of all certifications/denials and payor letters while appropriately prioritizing cases to adhere to specified timeframes for appeal

• Ensures utilization management departments work in conjunction with Patient Financial Services and Revenue Integrity to manage the appeal process in an effective manner in accordance with requirements of managed care contracts, federal and state laws, and department policies

• Collaborates with UM Manager to establish efficient workflow processes to ensure alignment with concurrent and retrospective denial management

• Collaborates with health care teams as needed to identify appropriate utilization of resources and ensure accurate reimbursement

• Ensures collaboration to resolve patient and provider issues

• Assists with short stay case monitoring for reimbursement

• Assists with timely review of short stay Medicare cases prior to final billing

• Assists with monitoring of Care Coordination EPIC Work Queues to ensure timely claims resolution

• Working knowledge of Commercial, Managed Medicaid and Managed Medicare Payers and Policies, Medicare and Medicaid Government Payers, and Third-party reimbursement Administrators

• Utilization Management, InterQual, Milliman Care Guidelines and payor guideline proficiency

• Participates in departmental, hospital wide, and Trinity Health Mid Atlantic meetings, training and audits as required

• Assists with appropriate case referral to the Utilization Management Committee per the Utilization Management Plan

• • In conjunction with the RN Manager and UM team, provides assistance with the on-boarding and orientation for Care Coordination colleagues as needed.

• Assists with coordinating and presenting education on criteria and other regulatory processes

• Assists clinical leadership to educate physicians and others on appropriate documentation related to medical necessity

• Ensures collaboration to resolve patient and provider issues

• Assists with short stay case monitoring for reimbursement

• Assists with timely review of short stay Medicare cases prior to final billing Assists with monitoring of Care Coordination EPIC Work Queues to ensure timely claims resolution

• Working knowledge of Commercial, Managed Medicaid and Managed Medicare Payers and Policies, Medicare and Medicaid Government Payers, and Third-party reimbursement Administrators

• Proficiency with Utilization Management, InterQual criteria and Milliman Care Guidelines as well as payor guidelines

• Participates in departmental, hospital wide, and Trinity Health Mid Atlantic meetings, training and audits as required

• In conjunction with the RN Manager and UM team, provides assistance with the on-boarding and orientation for Care Coordination colleagues as needed.

• Assists with coordinating and presenting education on criteria and other regulatory processes

• Assists clinical leadership to educate physicians and others on appropriate documentation related to medical necessity

• Other duties as assigned by RN Manager and Director of Care Coordination

Our Commitment to Diversity and Inclusion

Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.

Our Commitment to Diversity and Inclusion

Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.

EOE including disability/veteran