Utilization Review - Business Support Specialist: PT Weekends

Date Posted: 12/06/2016
Position Number: 54749
Location: Isabella

Allegheny Health Network is an integrated delivery network focused on preserving health care choice and providing affordable, high-quality care to the people in our communities. With more than 14,000 employees including 7,400 health care professionals, nearly 200 primary care and specialty care practices, Allegheny Health Network includes seven hospitals in Pennsylvania with nearly 2,400 licensed beds.

Allegheny Health Network’s clinical expertise ranges from primary care to the most complex surgical procedures. Services include cancer diagnosis and treatment, cardiovascular care, neurological and neurosurgical services, organ transplantation, orthopedic and rehabilitation services, and women’s health.

Department: Resource Center
Status: Part-time

Job Summary: This position is responsible for covering vast roles within the Utilization Review management team that include manging 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.

Job 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).
• Implements and organizes downgrades compliantly and per documentation.
• Investigates concerns for improper billing/coding practices and recommends corrective action, works collaboratively to understand denial/appeal management process and alert edits/rejections.
• Identifies trends with claim holds and denials and provides communication to all necessary parties.
• Communicates with all parties in a professional manner to alert of specific problem issues.
• Ensures confidentiality of all patient accounts by following HIPAA guidelines.
• Proficient with department software, analytical tools, basic coding and billing knowledge, and revenue cycle operational policies.
• Performs other duties as assigned or required.

Education: Bachelor's degree in health care related field desirable, but equivalent job experience will be considered

Complexity of Work: Working knowledge of the revenue cycle; Working knowledge of medical terminology and/or insurance claim filing; Working knowledge of accepted principles, practices and tools relating to general healthcare billing; Ability to recognize, research, and correct documentation discrepancies; Detail oriented, analytical and

Required Experience: Minimum three years' experience in healthcare environment or related field with exposure to healthcare coding, billing, reimbursement, registration, insurance verification. Minimum 1 year experience with medical necessity appeals is preferred Competency of inpatient and outpatient coding guidelines preferred