Job Description
The Utilization Management Payor Specialist reflects the mission, vision, and values of Northwestern Memorial, adheres to the organization’s Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards.
Responsibilities:
- Assists in the communication of clinical information provided by the Utilization Management/Denials Management Case Manager with all payors using a variety of methods, including faxing and verbal communication.
- Obtains timely payor determinations regarding certification of hospital stay and accurately records and conveys the determination to the Utilization Management/Denials Management Case Manager.
- Tracks and assures compliance with payor requests for information and communicates payor requests to Utilization Management/Denials Management Case Manager as needed.
- Documents and communicates denial information to the Utilization Management/Denials Management Case Manager.
- Provides feedback to Utilization Management/Denials Management Case Manager as needed regarding payor guidelines, issues, and determinations discovered during communication with payors.
- Ensures payor and customer satisfaction by utilizing effective communication and interpersonal skills.
- Provides entry, tracking, and trending of Quality and Documentation data and outcomes, as directed.
- Participates in Performance Improvement initiatives and performs other Case Management-related functions, as directed.
- Mails out appeals initiated by the Utilization Management/Denials Management Case Manager.
- Distributes and processes payor mail and faxes, including but not limited to, authorization and denial letters.
- Upholds the Northwestern Medicine policy on patient confidentiality.
- Assists with data preparation and the creation of presentation materials as needed for the Case Management Team.
- Scan all approvals and denial letters into Media tab in Epic.
- Follows up as needed with payor regarding pending appeal status.
Qualifications
Required:
- High school diploma
- Minimum of five years of healthcare experience
- Conversant with medical terminology
- Expertise and knowledge of third-party payor, Medicare/Medicaid guidelines
Preferred:
- Associate's Degree in healthcare related field
- Proficient in Case Management electronic systems (All Scripts system software, Epic)
- Utilization Management experience
Additional Information
Northwestern Medicine is an affirmative action/equal opportunity employer and does not discriminate in hiring or employment on the basis of age, sex, race, color, religion, national origin, gender identity, veteran status, disability, sexual orientation or any other protected status.
Benefits
We offer a wide range of benefits that provide employees with tools and resources to improve their physical, emotional, and financial well-being while providing protection for unexpected life events. Please visit our Benefits section to learn more.
