Under the leadership of the Utilization Review Manager, assists in collection of information and communication with insurance companies, and other external vendors.  Responsibilities include accurate data entry into various clinical information systems and communication with patients and families regarding their Medicare rights

1. Completion of the Medicare Outpatient Observation Notice (MOON) process on Medicare beneficiaries
2. Completion of the IMM process on Medicare beneficiaries by administering the initial important Message from Medicare (IMM) when notified to do so from utilization reviewers, as needed

3. To assist the staff by verifying benefits, obtaining insurance authorizations, calling in referrals and orders to external vendors and accurately entering data into clinical information systems
4. Establishes collaborative relationships with Utilization Review staff, Care Coordination staff, vendors, liaisons, and other members of the healthcare team in order to effectively and efficiently complete necessary services
5. Collects clinical information from provider as delegated by staff
6. Enters accurate data, authorizations, referrals, entries into Expanse in an accurate and timely fashion
7. Calls insurance companies for authorization, benefit verification and coverage information as necessary
8. Executes proper use of telephone and voice mail systems; incorporates service standards for telephone contact on a daily basis
9. Seeks input from staff for problem cases/situations
10. Provides superior customer service to providers and members
11. Communicates effectively with the department, as well as other departments in the DCH system
12. Performs specific projects as directed by manager
13. Acquires new skills needed for performing job functions as the healthcare delivery system changes
14. Participates as an active member of the team, offering suggestions and recommendations for more effective and efficient operations
15. Maintains confidentiality of member/provider information
16. Performs assigned work safely

Scope, Purpose, and frequency of Contacts

1. Frequent telephone contact with providers, provider office staff, hospital staff, other customers and vendors
2. Daily contact with management staff
3. Daily contact with community agencies and insurance companies’ representatives
4. Work closely with all care management staff

DCH Standards:

• Maintains performance, patient and employee satisfaction and financial standards as outlined in the performance evaluation.
• Performs compliance requirements as outlined in the Employee Handbook
• Must adhere to the DCH Behavioral Standards including creating positive relationships with patients/families, coworkers, colleagues and with self.

• Performs essential job functions in a manner that ensures the safety of patients, visitors and employees.
• Identifies and reduces unsafe practices that may result in harm to patients, visitors and employees.
• Recognizes and takes appropriate action to reduce risks and hazards to promote safety for patients, visitors and employees.

• Requires use of electronic mail, time and attendance software, learning management software and intranet.
• Must adhere to all DCH Health System policies and procedures.
• All other duties as assigned.

High school education or equivalent required.  Must be able to read, write legibly, speak, and comprehend English.  Additional skills include

• Knowledge of MIDAS, Expanse, and Microsoft products. Proficiency in use or ability to gain proficiency
• 20 WPM Typing skills required
• Knowledge of medical terminology is required
• Strong organization and superior communication skills are required
• Strong telephone communication skills
• Knowledge of the insurance authorization process is preferred
• Ability to use telephone communication system
• Ability to communicate orally and effectively
• Ability to maintain member, provider, and organization information confidentially
• Ability to cooperate and be flexible
• Ability to relate to individuals form diverse backgrounds

WORKING CONDITIONS

Physical:  Physical presence onsite is essential.  Hearing and vision must be normal or corrected within normal range.  Able to perform duties with or without reasonable accommodation.  Must have ability to tolerate prolonged periods of standing and walking.  Must have ability to move about at the nurses station and to walk short distances.  Ability to reach reasonable distances in any direction.  Must be able to move fingers in a coordinated manner.

Environmental:  Includes exposure hazard materials and/or cleaning solutions.

Psychological:  Includes receiving delegation, working with team members, addressing conflict, and communicating with all types of personalities specifically over the telephone.