Utilization Coordinator PACE ASL


: $64,580.00 - $104,060.00 /year *

Employment Type

: Full-Time


: Bilingual/Interpretation/Translation


The ArchCare Senior Life utilization review process ensures appropriate use of hospital resources to care for participants. The Utilization Coordinator (UC) role augments workflow and process to expedite reviews, and provides contact personnel to coordinate communication between ArchCare departments and partner hospital staff. The UC will assist with initiation and modification of hospital related authorizations and mitigate technical coding errors and conflict that prevent adjudication of claims. The UC will manage excel worksheets and assist with development/maintainance of utilization review reports. The UC should have excellent customer service and communication skills to promote coordination between ArchCare departments(ex. Claims and UR staff, IDT and UR Nurses ) as well as our partner hospital staff (UR, Medical Records etc) to expedite claim execution, prevent unnecessary grievances and promote common understanding of utilization process. The UC will also monitor and review claims and authorization data, report submission, and submit/ amend authorizations as needed to correct submission errors. The UC will assist UM staff with data documentation to ensure the effectiveness of the claims - authorization process to meet the various regulatory requirements. The UC will remain single point of contact for all Service Catalog entries required by the medical and clinical staff to ensure the integrity of the claims and authorizations of ASL outpatient services.


* Serves as liaison/resource to UM/UR nurses related to participants admitted to hospitals.
* Coordinate discharge planning workflows between UM team and clinical IDT staff to promote efficient hospital care and mitigate excess length of stay
* Acts as contact person for ArchCare sister departments and hospitals/ other HCF
* Has a working knowledge and understanding of utilization management process and assists other staff to understand the resultant process change.
* Assists with retrieval of hospital clinical information to promote timely submission of ED/Hospital authorizations with correct diagnosis and claims coding
* Coordinates hospital and utilization review meetings to review current state process and improvement planning
* Participates in Performance Improvement activities; Identifies trends in utilization management
* Submits reports to quality improvement for review and analysis
* Demonstrates analytic skills to obtain and interpret information related to billing, coding and claims
* Maintains a positive working relationship with insurers, physicians, sources, clinical staff, and management
* Carries out work according to agency policies and procedures and in such a manner to appropriately reflect and role model agency standards for timeliness, fairness, accuracy, personal appearance, productivity, and behavior.
* Attends all staff meetings and in-services
* Is proactive in identifying process improvement opportunities.
* Demonstrates knowledge to effectively instruct staff in utilization review process
* Encourages positive relationships among all disciplines within the organization.
* Participates on organizational performance improvement teams/projects
* Accept telephonic and faxed reviews
* Assist and coordinate referrals for inter-hospital transfers and specialty care.
* Assist with disposition of Approval and Denial letters based on Medical Director determination
* Expeditiously alert providers by phone of denials.
* Appropriately refer cases to re-insurer in a timely manner.
* Must comply with all ArchCare Senior Life policies and procedures.
* Perform follow-up phone calls to facilitate obtaining of documents for any member visit or admission to Facilities, ER and/or Hospital.
* Maintain confidentiality of all member information in compliance with HIPAA requirements.


License Requirements

* Bachelors Degree

Skill Requirements

Must have ability to analyse data, assist with report generation, manage / read claims reportsMust have the ability to monitor and review claims and authorization data, report submission, and submit/ amend authorizations to correct submission errorsMust have the ability to communicate effectively in English. Must be self-motivated and possess the ability to solve problems independentlyMust be committed to being a patient advocate Must have the ability to work with other professional and para-professional staff in a collaborative manner. Must be a team player Must display a commitment to quality in practice and documentationMust be able to follow through on all projects in a timely manner. Must possess computer knowledge and demonstrate proficiency with excel, report maintenance and word. Must show a willingness to learn more advanced skills

* The salary listed in the header is an estimate based on salary data for similar jobs in the same area. Salary or compensation data found in the job description is accurate.

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