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.
00518679
Seniority level
Entry level
Employment type
Full-time
Job function
Project Management and Information Technology
Industries
Hospitals and Health Care
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