MINIMUM QUALIFICATIONS:
EDUCATION, CERTIFICATION, AND/OR LICENSURE:
1. High School Diploma or equivalent
EXPERIENCE:
1. Two years’ experience in healthcare setting
2. Payor relations experience
3. Administrative/clerical experience
CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.
1. Responsible for completion of all utilization review functions for patients admitted to an organizational units/location, including but not limited to, notification of admission, communication of medical record information to payors, and processing of denials.
2. Communicates payor determinations and level of care coverage determinations to the applicable patient care team members.
3. Provides timely and comprehensive documentation of next review dates, authorization, covered days, and denials according to payer guidelines and departmental procedures.
4. Maintains multiple insurance forms from but not limited to Medicaid, Federal Compensation, and other various companies.
5. Follows up on accounts as directed.
6. Required weekend/holiday rotations as assigned by leadership.
7. Foster positive and professional relationships and liaise with internal and external customers to ensure effective working relationships and team building to facilitate the review process.
8. Communicates problems hindering workflow to leadership in a timely manner
9. Appropriately escalates concerns regarding correct insurance coverage.
10. Performs reception functions in a positive and helpful manner
11. Actively cross-trains to perform duties to provide flexible workforce to meet business needs of the department.
12. Responsible for attending training and scheduled meetings and maintaining and using current/updated information for review.
13. Maintains assigned work que volumes and productivity goals
14. Maintains patient confidentiality and adheres strictly to the departmental code of ethics.
15. Precept newly hired team members as assigned by leadership
16. Maintain subject matter expertise in assigned payor, including payor requirements and portal access, if applicable.
17. Effectively support clinical team members in communicating and liaison with insurances/payors
18. Fulfill administrative support duties as needed by the department, including the triage and management of incoming faxes and voicemail.
PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
1. Office work which includes sitting for extended periods of time.
2. Must have reading and comprehension ability.
3. Visual acuity must be within normal range.
4. Must be able to communicate effectively.
5. Must have manual dexterity to operate keyboards, fax machines, telephones and other business equipment.
WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
1. Office work which includes sitting for extended periods of time.
2. Maintains confidential home office space
SKILLS & ABILILTIES:
1. Effective verbal and written communication skills.
2. Strong interpersonal skills.
3. Strong attention to detail.
4. Knowledge of medical terminology preferred.
5. Knowledge of third party payers required.
6. Ability to use tact and diplomacy in dealing with others.
7. Working knowledge of computers.
8. Excellent customer service and telephone etiquette
Additional Job Description:
Scheduled Weekly Hours:
40Shift:
Exempt/Non-Exempt:
United States of America (Non-Exempt)Company:
SYSTEM West Virginia University Health SystemCost Center:
553 SYSTEM Utilization Review
What We Do
The WVU Health System, which operates under the brand name WVU Medicine, is comprised of 22 member, managed, and affiliated hospitals in West Virginia, Maryland, Ohio, and Pennsylvania. It is West Virginia’s largest healthcare system and largest private employer with more than 2,500 licensed beds, 4,900 providers, approximately 30,000 employees, and more than $5 billion in total operating revenues.
It includes:
• J.W. Ruby Memorial Hospital in Morgantown (flagship), including WVU Medicine Children’s in Morgantown and Fairmont Medical Center in Fairmont;
• United Hospital Center in Bridgeport;
• Camden Clark Medical Center in Parkersburg;
• Berkeley Medical Center in Martinsburg;
• Barnesville Hospital in Barnesville, Ohio;
• Braxton County Memorial Hospital in Gassaway;
• Garrett Regional Medical Center in Oakland, Maryland;
• Harrison Community Hospital in Cadiz, Ohio;
• Jackson General Hospital in Ripley;
• Jefferson Medical Center in Ranson;
• Potomac Valley Hospital in Keyser;
• Princeton Community Hospital in Princeton, including The Behavioral Health Pavilion in Bluefield;
• Reynolds Memorial Hospital in Glen Dale;
• Saint Francis Hospital in Charleston;
• St. Joseph’s Hospital in Buckhannon;
• Summersville Regional Medical Center in Summersville;
• Thomas Memorial Hospital in South Charleston;
• Uniontown Hospital in Uniontown, Pennsylvania;
• Wetzel County Hospital in New Martinsville;
• Wheeling Hospital in Wheeling;
• And five institutes – the WVU Cancer Institute, the WVU Critical Care and Trauma Institute, the WVU Eye Institute, the WVU Heart and Vascular Institute, and the WVU Rockefeller Neuroscience Institute.
The WVU Health System also provides management services to Grant Memorial Hospital in Petersburg.
For more information, visit WVUMedicine.org
