utilization management specialist

Highmark Health

<div><h2 class="jobSectionHeader"><b>Company :
</b></h2>Highmark Inc.
<h2 class="jobSectionHeader"><b>Job Description :
</b></h2><p><b>JOB SUMMARY
</b></p><p>This job implements effective utilization management strategies including: review of appropriateness of health care services, application of criteria to ensure appropriate resource utilization, identification of opportunities for referral to a Health Coach/case management, and identification and resolution of quality issues. Monitors and analyzes the delivery of health care services; educates providers and members on a proactive basis; and analyzes qualitative and quantitative data in developing strategies to improve provider performance/satisfaction and member satisfaction. Responds to customer inquiries and offers interventions and/or alternatives.
</p><p></p><p><b>ESSENTIAL RESPONSIBILITIES
</b></p><ul><li><p>Implement care management review processes that are consistent with established industry and corporate standards and are within the care manager&rsquo;s professional discipline.
</p></li><li><p>Function in accordance with applicable state, federal laws and regulatory compliance.
</p></li><li><p>Implement all care management reviews according to accepted and established criteria, as well as other approved guidelines and medical policies.
</p></li><li><p>Promote quality and efficiency in the delivery of care management services.
</p></li><li><p>Respect the member&rsquo;s right to privacy, sharing only information relevant to the member&rsquo;s care and within the framework of applicable laws.
</p></li><li><p>Practice within the scope of ethical principles.
</p></li><li><p>Identify and refer members whose healthcare outcomes might be enhanced by Health Coaching/case management interventions.
</p></li><li><p>Employ collaborative interventions which focus, facilitate, and maximize the member&rsquo;s health care outcomes. Is familiar with the various care options and provider resources available to the member.
</p></li><li><p>Educate professional and facility providers and vendors for the purpose of streamlining and improving processes, while developing network rapport and relationships.
</p></li><li><p>Develop and sustain positive working relationships with internal and external customers.
</p></li><li><p>Utilize outcomes data to improve ongoing care management services.
</p></li><li><p>Other duties as assigned or requested
</p></li></ul><p></p><p><b>EDUCATION
</b></p><p><b>Required
</b></p><ul><li><p>None
</p></li></ul><p></p><p><b>Substitutions
</b></p><ul><li><p>None
</p></li></ul><p></p><p><b>Preferred
</b></p><ul><li><p>Bachelor&rsquo;s Degree in Nursing
</p></li></ul><p></p><p><b>EXPERIENCE
</b></p><p><b>Required
</b></p><ul><li><p>3 years of related, progressive clinical experience in the area of specialization
</p></li><li><p>Experience in a clinical setting
</p></li></ul><p></p><p><b>Preferred
</b></p><ul><li><p>Experience in UM/CM/QA/Managed Care
</p></li></ul><p></p><p><b>LICENSES AND CERTIFICATIONS
</b></p><p><b>Required
</b></p><ul><li><p>Current State of PA RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC). Additional specific state licensure(s) may be required depending on where clinical care is being provided.
</p></li></ul><p></p><p><b>Preferred
</b></p><ul><li><p>Certification in utilization management or a related field
</p></li></ul><p></p><p><b>SKILLS
</b></p><ul><li><p>Working knowledge of pertinent regulatory and compliance guidelines and medical policies
</p></li><li><p>Ability to multi task and perform in a fast paced and often intense environment
</p></li><li><p>Excellent written and verbal communication skills
</p></li><li><p>Ability to analyze data, measure outcomes, and develop action plans
</p></li><li><p>Be enthusiastic, innovative, and flexible
</p></li><li><p>Be a team player who possesses strong analytical and organizational skills
</p></li><li><p>Demonstrated ability to prioritize work demands and meet deadlines
</p></li><li><p>Excellent computer and software knowledge and skills
</p></li></ul><p></p><p><b>Languages (Other than English)
</b></p><p>None<br>
</p><p><br>
<b>Travel Requirement
</b></p><p>0% - 25%
</p><p></p><p><b>PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
</b></p><p><b>Position Type
</b></p><p>Office-Based
</p><p></p><p>Teaches/trains others regularly
</p><p>Occasionally
</p><p></p><p>Travel regularly from the office to various work sites or from site-to-site
</p><p>Does Not Apply
</p><p></p><p>Works primarily out-of-the office selling products/services (sales employees)
</p><p>Does Not Apply
</p><p></p><p>Physical work site required
</p><p>Yes
</p><p></p><p>Lifting: up to 10 pounds
</p><p>Constantly
</p><p></p><p>Lifting: 10 to 25 pounds
</p><p>Occasionally
</p><p></p><p>Lifting: 25 to 50 pounds
</p><p>Rarely, Occasionally
</p><p></p><p><b><i>Disclaimer: </i></b><i>The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
</i></p><p></p><p><b><i>Compliance Requirement: </i></b><i>This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
</i></p><p></p><p><i>As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company&rsquo;s Handbook of Privacy Policies and Practices and Information Security Policy.
</i></p><p></p><p><i>Furthermore, it is every employee&rsquo;s responsibility to comply with the company&rsquo;s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.
</i></p><p><b>Pay Range Minimum:
</b></p>$68,400.00
<p></p><p><b>Pay Range Maximum:
</b></p>$105,900.00
<p></p><p><i>Base pay is determined by a variety of factors including a candidate&rsquo;s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.
</i></p><p></p><p>Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.
</p><p></p><p>We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below.
</p><p></p><p>For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org
</p><p></p><p>California Consumer Privacy Act Employees, Contractors, and Applicants Notice</p></div>

Care Manager RN (Remote)

<div><h2 class="jobSectionHeader"><b>Company :
</b></h2>Highmark Inc.
<h2 class="jobSectionHeader"><b>Job Description :
</b></h2><p><b>JOB SUMMARY
</b></p><p></p><p>This job is responsible for completing all Prior Authorization outbound call tasks and/or inbound triage case creations. In compliance with regulatory guidelines (e.g., NCQA, CMS), the incumbent informs the member and/or provider of the approval and/or denial of the requested authorization.
<br>
<br>
<b>ESSENTIAL RESPONSIBILITIES
</b></p><ul><li><p>Obtain call task from Utilization Management platform, perform verbal outbound call task requirement following a detailed script and desk level procedure, and appropriately log result within the platform.
</p></li><li><p>Obtain triage task from Utilization Management platform and follow a detailed desk level procedure to enter the required fields to set up the case build (data entry) and set the urgency of the case creation for the Intake Coordinator.
</p></li><li><p>Other duties as assigned or requested.
</p></li></ul><p></p><p><b>EXPERIENCE<br>
</b></p><p><br>
<b>Required
</b></p><ul><li><p>1 year of Healthcare experience
</p></li><li><p>1 year of Customer Service experience
</p></li></ul><p></p><p><b>Preferred
</b></p><ul><li><p>1 year of Call Center experience<br>
</p></li></ul><p><br>
<b>SKILLS
</b></p><ul><li><p>Possess good written and oral telephonic communication skills
</p></li><li><p>Ability to navigate through multiple systems simultaneously
</p></li><li><p>Knowledge of administrative and clerical procedures and systems such as word processing, managing files and digital fax
</p></li><li><p>Ability to interact well with peers, supervisors, and customers<br>
</p></li></ul><p><br>
<b>EDUCATION<br>
</b></p><p><br>
<b>Required
</b></p><ul><li><p>High School Diploma<br>
</p></li></ul><p><br>
<b>Preferred
</b></p><ul><li><p>None<br>
</p></li></ul><p><br>
<b>LICENSES or CERTIFICATIONS<br>
</b></p><p><br>
<b>Required
</b></p><ul><li><p>None<br>
</p></li></ul><p><br>
<b>Preferred
</b></p><ul><li><p>None<br>
</p></li></ul><p><br>
<b>Language (Other than English):
</b></p><p>None
</p><p></p><p><b>Travel Requirement:
</b></p><p>0% - 25%
</p><p></p><p><b>PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
</b></p><p></p><p><b>Position Type
</b></p><p>Office- or Remote-based
</p><p></p><p>Physical work site required
</p><p>Constantly
</p><p></p><p>Travel Required
</p><p>0% - 25%
</p><p></p><p>Audible Speech
</p><p>Frequently
</p><p></p><p>Hear
</p><p>Frequently
</p><p></p><p>Position self or move lower on ground, under tables/desk, etc.
</p><p>Occasionally
</p><p></p><p>Climb
</p><p>Occasionally
</p><p></p><p>Drive
</p><p>Never
</p><p></p><p>Reach
</p><p>Occasionally
</p><p></p><p>Sedentary Position
</p><p>Constantly
</p><p></p><p>Move
</p><p>Occasionally
</p><p></p><p>Repetitive Motion
</p><p>Constantly
</p><p></p><p>Use Hands/Fingers to Handle or Feel (beyond data entry)
</p><p>Occasionally
</p><p></p><p>Vision - Distinguish Color
</p><p>Occasionally
</p><p></p><p>Vision - Far, near, Depth Perception
</p><p>Occasionally
</p><p></p><p>Lifting: up to 10 pounds
</p><p>Constantly
</p><p></p><p>Lifting: up to 20 pounds
</p><p>Occasionally
</p><p></p><p>Lifting: up to 50 pounds
</p><p>Never
</p><p></p><p>Lifting in excess of 50 pounds
</p><p>Never
</p><p></p><p><b><i>Disclaimer: </i></b><i>The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
</i><br>
<br>
<b><i>Compliance Requirement </i></b><i>: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
</i><br>
<br>
<i>As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company&rsquo;s Handbook of Privacy Policies and Practices and Information Security Policy.
</i><br>
<br>
<i>Furthermore, it is every employee&rsquo;s responsibility to comply with the company&rsquo;s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.
</i></p><p><b>Pay Range Minimum:
</b></p>$19.39
<p></p><p><b>Pay Range Maximum:
</b></p>$24.19
<p></p><p><i>Base pay is determined by a variety of factors including a candidate&rsquo;s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.
</i></p><p></p><p>Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.
</p><p></p><p>We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact the email below.
</p><p></p><p>For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org
</p><p></p><p>California Consumer Privacy Act Employees, Contractors, and Applicants Notice</p></div>

Associate Intake Coordinator

Fakeeh Care Group

<div>
 <strong>
  Description
  <br/>
  <br/>
 </strong>
 Key Responsibilities and Duties:
 <br/>
 <br/>
 <ul>
  <li>
   Ensure full adherence to the Council of Health Insurance (CHI) Preauthorization Policy, NPHIES standards, and
   <br/>
   <br/>
  </li>
 </ul>
 individual payer coverage protocols.
 <br/>
 <br/>
 <ul>
  <li>
   Prevent unauthorized, uncovered, or non-contracted services from being initiated.
  </li>
  <li>
   Support the implementation and compliance of NPHIES downtime contingency procedures.
  </li>
  <li>
   Verify the completeness of clinical documentation and utilization of the Minimum Data Set (MDS) for every
   <br/>
   <br/>
  </li>
 </ul>
 request.
 <br/>
 <br/>
 <ul>
  <li>
   Review the treating physician&rsquo;s progress notes, diagnostics, prescriptions, and clinical justifications for
   <br/>
   <br/>
  </li>
 </ul>
 accuracy and adequacy.
 <br/>
 <br/>
 <ul>
  <li>
   Validate medical necessity in alignment with evidence-based guidelines, CHI standards, and payer criteria.
  </li>
  <li>
   Ensure accurate clinical coding and scheme linkage to prevent claim denials.
  </li>
  <li>
   Escalate incomplete or inaccurate documentation for correction prior to submission.
  </li>
  <li>
   Liaise with treating physicians, nurses, and roving doctors to secure approvals and clarify case details.
  </li>
  <li>
   Communicate approvals, denials, and payer queries within CHI-mandated timelines.
  </li>
  <li>
   Respond to payer or insurer queries within 30 minutes of receipt.
  </li>
  <li>
   Escalate urgent or high-priority cases (ER, ICU, Oncology, or high-cost procedures) immediately to the
   <br/>
   <br/>
  </li>
 </ul>
 Preauthorization Manager.
 <br/>
 <br/>
 <ul>
  <li>
   Monitor HIS/NPHIES queues to follow up on pending or queried cases in real time.
  </li>
  <li>
   Maintain updated approval status in both HIS and the patient&rsquo;s record.
  </li>
  <li>
   Ensure 100% completion of approvals for all discharges within the same day.
  </li>
  <li>
   Confirm that same-day discharge and high-cost cases are fully approved prior to billing.
  </li>
  <li>
   Document all approvals, denials, and payer communications in the patient&rsquo;s medical record.
  </li>
  <li>
   Participate in the daily discharge reconciliation process and report pending approvals to the Preauthorization
   <br/>
   <br/>
  </li>
 </ul>
 Manager.
 <br/>
 <br/>
 <ul>
  <li>
   Review all preauthorization rejections received through NPHIES, payer portals, or HIS at least twice per shift.
  </li>
  <li>
   Categorize rejections based on cause (missing justification, duplication, non-covered service, exceeded limit,
   <br/>
   <br/>
  </li>
 </ul>
 coding error, or late submission).
 <br/>
 <br/>
 <ul>
  <li>
   Record all rejections in the Rejection Tracker Log with patient MRN, preauthorization number, payer,
   <br/>
   <br/>
  </li>
 </ul>
 rejection reason, and physician name.
 <br/>
 <br/>
 <ul>
  <li>
   Coordinate with the Preauthorization Supervisor to ensure each rejection is reviewed and analyzed within the
   <br/>
   <br/>
  </li>
 </ul>
 assigned TAT.
 <br/>
 <br/>
 <ul>
  <li>
   Engage directly with the treating physician for clarification or missing documentation related to rejected
   <br/>
   <br/>
  </li>
 </ul>
 cases.
 <br/>
 <br/>
 <ul>
  <li>
   Provide constructive feedback and guidance to physicians to avoid recurrence, referencing insurer
   <br/>
   <br/>
  </li>
 </ul>
 preauthorization protocols, CHI guidelines and NPHIES dataset requirements.
 <br/>
 <br/>
 <ul>
  <li>
   Conduct same-day briefings for rejections involving high-cost services.
  </li>
  <li>
   Resubmit corrected documentation within the payer&rsquo;s appeal window as per the regulations.
  </li>
  <li>
   Liaise with the insurance representative or roving doctor for urgent or high-priority resubmissions.
  </li>
  <li>
   Confirm acknowledgment of resubmitted cases in both HIS and payer portals.
  </li>
  <li>
   Identify root causes for all rejections and document corrective recommendations.
  </li>
  <li>
   Distinguish between avoidable and non-avoidable rejections during end-of-day analysis.
  </li>
  <li>
   Submit a daily rejection summary to the Preauthorization Manager, covering:
  </li>
  <li>
   Total rejections received
  </li>
  <li>
   Avoidable vs non-avoidable ratio
  </li>
  <li>
   High-value or repetitive rejection patterns
  </li>
  <li>
   Breakdown by payer, physician, and service category
  </li>
  <li>
   Recommend corrective actions such as MDS checklist updates, justification templates, or focused physician
   <br/>
   <br/>
  </li>
 </ul>
 sessions.
 <br/>
 <br/>
 <ul>
  <li>
   Collaborate with Fakeeh Tech to improve HIS alerts (e.g., auto-flagging incomplete documentation or
   <br/>
   <br/>
  </li>
 </ul>
 incorrect scheme linkage).
 <br/>
 <br/>
 <ul>
  <li>
   Participate in weekly Preauthorization Group performance meetings to present rejection trends and lessons
   <br/>
   <br/>
  </li>
 </ul>
 learned.
 <br/>
 <br/>
 <ul>
  <li>
   Ensure complete transparency of all rejection cases to the Preauthorization Manager and Group
   <br/>
   <br/>
  </li>
 </ul>
 Preauthorization leadership.
 <br/>
 <br/>
 <ul>
  <li>
   Support the preparation of a Weekly Rejection Dashboard, including:
  </li>
  <li>
   Total rejection count
  </li>
  <li>
   Avoidable vs non-avoidable percentage
  </li>
  <li>
   Average approval turnaround time
  </li>
  <li>
   Top 10 contributing services, physicians, or payers
  </li>
  <li>
   Highlight immediate corrective actions taken and propose follow-up actions for recurring issues.
  </li>
  <li>
   Uphold professional communication standards and maintain formal documentation of all internal and
   <br/>
   <br/>
  </li>
 </ul>
 external correspondences.
 <br/>
 <br/>
 <ul>
  <li>
   Ensure continuous compliance with CHI, NPHIES, and contractual payer regulations in every stage of
   <br/>
   <br/>
  </li>
 </ul>
 preauthorization and rejection management.
 <br/>
 <br/>
 <ul>
  <li>
   Report any non-compliance or process deviation to the Preauthorization Manager for immediate rectification
   <br/>
   <br/>
  </li>
 </ul>
 and inclusion in preauthorization Group review.
 <br/>
 <br/>
 <ul>
  <li>
   Other duties as assigned within the scope of responsibility and requirements of the job.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Requirements
  <br/>
  <br/>
 </strong>
 Experience: 3&ndash;5 years clinical practice, with at least 2 years in preauthorization/insurance or
 <br/>
 <br/>
 utilization management
 <br/>
 <br/>
 Education: Bachelor&rsquo;s degree in medicine and surgery, Pharmacy, Dental or related field.
 <br/>
 <br/>
 Language: Excellent command of oral and written English and Arabic.
 <br/>
 <br/>
 <strong>
  Licenses / Certifications
  <br/>
  <br/>
 </strong>
 Preferred license for practice as per the regional health regulatory authority e.g.
 <br/>
 <br/>
 (SCFHS / DHA).
</div>


Approval Specialist

DataAnnotation

<div>
 We are looking for a
 <strong>
  Clinical Appeals Nurse
 </strong>
 to join our team to train AI models. You will measure the progress of these AI chatbots, evaluate their logic, and solve problems to improve the quality of each model.
 <br/>
 <br/>
 In this role, you will need to be an expert in healthcare. We are interested in a wide range of expertise, so relevant backgrounds include Clinical Documentation &amp; HIM, Medication Management (PharmD), Laboratory Medicine and Pathology Services (MLS, MD), Quality Improvement &amp; Patient Safety, Regulatory Compliance, Accreditation &amp; Medical Staff, Care Coordination &amp; Case Management, Population Health &amp; Value-Based Care, and Managed Care &amp; Utilization Management.
 <br/>
 <br/>
 <strong>
  Benefits
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Full-time or part-time remote position
  </li>
  <li>
   Choose which projects you want to work on
  </li>
  <li>
   Flexible schedule
  </li>
  <li>
   Projects are paid hourly starting at $50+ per hour
  </li>
  <li>
   Bonuses available for high-quality and high-volume work
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Responsibilities
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Provide AI chatbots with diverse and complex healthcare-related problems
  </li>
  <li>
   Evaluate AI outputs for logic, accuracy, and performance
  </li>
  <li>
   Ensure the medical accuracy and overall quality of model responses
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Qualifications
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Fluency in English (native or bilingual level)
  </li>
  <li>
   A current or in-progress medical or healthcare-related degree
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Notes:
 </strong>
 Payment is made via PayPal. We will never ask you for any money. PayPal will handle any currency conversions from USD. Only applicants in the United States will be considered for this role. This is an independent contractor position.
 <br/>
 <br/>
 <em>
  #medicine
 </em>
</div>


Clinical Appeals Nurse

Valley Medical Center

<div></div><div><div><div><ul><li><h6 class="jobSectionHeader"><b>Job Title:</b></h6>
 Clinical Documentation Specialist
</li><li><h6 class="jobSectionHeader"><b>Req:</b></h6>
 2026-0293
</li><li><h6 class="jobSectionHeader"><b>Location:</b></h6>
 VMC Main Campus
</li><li><h6 class="jobSectionHeader"><b>Department:</b></h6>
 Health Information Mgmt
</li><li><h6 class="jobSectionHeader"><b>Shift:</b></h6>
 Days
</li><li><h6 class="jobSectionHeader"><b>Type:</b></h6>
 Full Time
</li><li><h6 class="jobSectionHeader"><b>FTE:</b></h6>
 1
</li><li><h6 class="jobSectionHeader"><b>Hours:</b></h6>
</li><li><h6 class="jobSectionHeader"><b>City State:</b></h6>
 Renton, WA
</li><li><h6 class="jobSectionHeader"><b>Salary Range:</b></h6>
 Min $94,894 - Max $142,341/annual DOE</li></ul></div></div><br>
<br>
<br>
<br>
<p></p><p><b>Job Description:</b></p>
<p>VALLEY MEDICAL CENTER</p>
<p>
</p><p><b>JOB DESCRIPTION</b></p>
<p>
</p><p>The position description is a guide to the critical duties and essential functions of the job, not an all-inclusive list of responsibilities, qualifications, physical demands, and work environment conditions. Position descriptions are reviewed and revised to meet the changing needs of the organization.</p>
<p>
</p><p><b>TITLE:</b> Clinical Documentation Specialist RN</p>
<p>
</p><p><b>JOB OVERVIEW:</b> The Clinical Documentation Specialist position facilitates accurate documentation for severity of illness and quality in the medical record. This involves extensive record review, interaction with physicians, health information management professionals, and nursing staff. Active participation in team meetings and education of staff in the documentation improvement process is a key role.</p>
<p>
</p><p><b>DEPARTMENT:</b> Health Information Management</p>
<p>
</p><p><b>HOURS OF</b> <b>WORK:</b> Days Monday - Friday.</p>
<p>
</p><p><b>RESPONSIBLE TO:</b> Manager, Clinical Documentation Improvement</p>
<p>
</p><p>PREREQUISITES:</p>
<div>
<ul><li><p>Current unrestricted WA State Registered Nurse license, required.</p>
</li></ul>
<ul><li><p>Bachelor's degree in Nursing, preferred.</p>
</li></ul>
<ul><li><p>Minimum five years recent clinical experience as an RN working in an acute care setting or with experience in Utilization Review</p>
</li></ul>
<ul><li><p>Pass a pre-hire Clinical Exam with a minimum score of 70%</p>
</li></ul>
<ul><li><p>Effective communication with Providers</p>
</li></ul>
</div><p></p><p>QUALIFICATIONS:</p>
<div>
<ul><li><p>Knowledge of hospital clinical practice standards for physicians and other health care providers.</p>
</li></ul>
<ul><li><p>Knowledge of ancillary service departments, quality control and safety standards.</p>
</li></ul>
<ul><li><p>Critical thinking, problem solving and deductive reasoning skills.</p>
</li></ul>
<ul><li><p>Familiarity with health care audit and research design.</p>
</li></ul>
<ul><li><p>Knowledge of Pathophysiology and Disease process.</p>
</li></ul>
<ul><li><p>Functional knowledge of DRG coding systems.</p>
</li></ul>
<ul><li><p>Working experience with Utilization Review activities and general knowledge of JCAHO, PRO, HCFA, and other regulatory bodies.</p>
</li></ul>
<ul><li><p>Knowledge of third-party payer review, reimbursement systems and utilization monitoring requirements for acute care facilities.</p>
</li></ul>
<ul><li><p>Meet productivity guidelines.</p>
</li></ul>
<ul><li><p>Ability to learn/develop the skills necessary to perform and meet goal standards</p>
</li></ul>
<ul><li><p>Organizational, analytical, writing, and interpersonal skills</p>
</li></ul>
<ul><li><p>Dependable, self-directed, and pleasant</p>
</li></ul>
<ul><li><p>Critical thinking, problem solving and deductive reasoning skills</p>
</li></ul>
<ul><li><p>Knowledge of Pathophysiology and Disease Process</p>
</li></ul>
<ul><li><p>Basic Computer skills - familiarity with Windows based software programs</p>
</li></ul>
<ul><li><p>Knowledge of regulatory environment</p>
</li></ul>
<ul><li><p>Understand and support documentation strategies (upon completion of training)</p>
</li></ul>
<ul><li><p>Knowledge of Core Measure and Patient Safety Indicators (upon completion of training)</p>
</li></ul>
</div><p></p><p>UNIQUE PHYSICAL/MENTAL DEMANDS, ENVIRONMENT AND WORKING CONDITIONS:</p>
<p>
See Generic Job Description for Administrative Partner.</p>
<p>
</p><p>PERFORMANCE RESPONSIBILITIES:</p>
<p>
A. Generic Job Functions: <i>See Generic Job Description for Administrative Partner.</i></p>
<p>
B. Essential Responsibilities and Competencies</p>
<div>
<ul><li><p>Reviews EMR for completeness and accuracy for severity of illness and quality using the documentation strategies.</p>
</li></ul>
<ul><li><p>Accurate and timely record review.</p>
</li></ul>
<ul><li><p>Recognize opportunities for documentation improvement.</p>
</li></ul>
<ul><li><p>Initiates severity worksheet for inpatients.</p>
</li></ul>
<ul><li><p>Formulate clinically credible documentation clarifications.</p>
</li></ul>
<ul><li><p>Request documentation clarifications as appropriate for SOI, Core Measures, and Patient Safety.</p>
</li></ul>
<ul><li><p>Effective and appropriate communication with physicians.</p>
</li></ul>
<ul><li><p>Timely follow up on all cases and resolution of those with clinical documentation clarifications.</p>
</li></ul>
<ul><li><p>Communicates with HIM staff and resolves discrepancies.</p>
</li></ul>
<ul><li><p>Accurate input of data for reconciliation of case.</p>
</li></ul>
<ul><li><p>Provide necessary information and education to physicians and staff to facilitate the appropriate documentation goals.</p>
</li></ul>
<ul><li><p>Identify any barriers to completion of documentation goals with appropriate interventions.</p>
</li></ul>
<ul><li><p>Review of regulations and coding guidelines through seminars, meetings, and materials.</p>
</li></ul>
<ul><li><p>In cooperation with the director of PFS/HIM, present education sessions to physicians and other VMC providers regarding documentation regulations and chart audit findings.</p>
</li></ul>
<ul><li><p>Maintains confidentiality of all accessible patient financial or medical records information.</p>
</li></ul>
<ul><li><p>Demonstrates the awareness of the importance of cost containment for the department. Provide suggestions regarding process or quality improvement opportunities to department manager.</p>
</li></ul>
<ul><li><p>Other duties as assigned to facilitate accurate, timely patient account management.</p>
</li></ul>
</div><p></p><p>Date Created: 5/18, updated 7/22</p>
<p>
Grade: NC11</p>
<p>
FLSA: E</p>
<p>
Cost Center: 8490</p><br>
<p><b>
Job Qualifications:</b></p>
<p>PREREQUISITES:</p>
<div>
<ul><li><p>Current unrestricted WA State Registered Nurse license, required.</p>
</li></ul>
<ul><li><p>Bachelor's degree in Nursing, preferred.</p>
</li></ul>
<ul><li><p>Minimum five years recent clinical experience as an RN working in an acute care setting or with experience in Utilization Review</p>
</li></ul>
<ul><li><p>Pass a pre-hire Clinical Exam with a minimum score of 70%</p>
</li></ul>
<ul><li><p>Effective communication with Providers</p>
</li></ul>
</div><p></p><p>QUALIFICATIONS:</p>
<div>
<ul><li><p>Knowledge of hospital clinical practice standards for physicians and other health care providers.</p>
</li></ul>
<ul><li><p>Knowledge of ancillary service departments, quality control and safety standards.</p>
</li></ul>
<ul><li><p>Critical thinking, problem solving and deductive reasoning skills.</p>
</li></ul>
<ul><li><p>Familiarity with health care audit and research design.</p>
</li></ul>
<ul><li><p>Knowledge of Pathophysiology and Disease process.</p>
</li></ul>
<ul><li><p>Functional knowledge of DRG coding systems.</p>
</li></ul>
<ul><li><p>Working experience with Utilization Review activities and general knowledge of JCAHO, PRO, HCFA, and other regulatory bodies.</p>
</li></ul>
<ul><li><p>Knowledge of third-party payer review, reimbursement systems and utilization monitoring requirements for acute care facilities.</p>
</li></ul>
<ul><li><p>Meet productivity guidelines.</p>
</li></ul>
<ul><li><p>Ability to learn/develop the skills necessary to perform and meet goal standards</p>
</li></ul>
<ul><li><p>Organizational, analytical, writing, and interpersonal skills</p>
</li></ul>
<ul><li><p>Dependable, self-directed, and pleasant</p>
</li></ul>
<ul><li><p>Critical thinking, problem solving and deductive reasoning skills</p>
</li></ul>
<ul><li><p>Knowledge of Pathophysiology and Disease Process</p>
</li></ul>
<ul><li><p>Basic Computer skills - familiarity with Windows based software programs</p>
</li></ul>
<ul><li><p>Knowledge of regulatory environment</p>
</li></ul>
<ul><li><p>Understand and support documentation strategies (upon completion of training)</p>
</li></ul>
<ul><li><p>Knowledge of Core Measure and Patient Safety Indicators (upon completion of training)</p></li></ul></div></div><p></p>

Clinical Documentation Specialist

L.A. Care Health Plan

<div></div><div><div><div><div><div><div><div><p>Authorization Technician II
</p></div></div></div></div><div><div><div><div><b>Job Category: </b>Clinical
</div></div></div></div><div><div><div><div><b>Department: </b>Utilization Management
</div></div></div></div><div><div><div><div><b>Location:
</b>Los Angeles, CA, US, 90017
</div></div></div></div><div><div><div><div><b>Position Type: </b>Full Time
</div></div></div></div><div><div><div><div><b>Requisition ID: </b>13058
</div></div></div></div><div><div><div><div><div><b>Salary Range:</b> $47,840.00 (Min.) - $57,062.00 (Mid.) - $68,474.00 (Max.)</div><br>
<div></div>
<div>Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation&rsquo;s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.<br>
<br>
Mission: L.A. Care&rsquo;s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.<br>
</div><div><div><div><div>Job Summary</div>
</div><div><div>
The Authorization Technician II supports the Utilization Management (UM) Specialist by handling all administrative and technical functions of the authorization process including intake, logging, tracking and status follow-up.</div><br>
<div></div>
<div>The Authorization Technician II collects information required by clinical staff to render decisions, assists the Manager and Director of the Utilization Management department in meeting regulatory time lines by maintaining an accurate database inventory of referral authorizations, retrospective reviews, concurrent reviews and grievance/appeal requests, and prepares UM Activity and Weekly Compliance Reports.</div><br>
<div></div>
<div>In addition, the position performs data entry and processing of referrals/authorizations in the system, authorizes request consistent with auto authorization criteria, maintains confidentiality when communicating member information, and assists with the communication of determinations by preparing template letters for members/ providers, with other duties as assigned.</div>
</div></div><div><div><div>
Duties</div>
</div><div><div>Functional Elements: Technical Support to UM Specialist: Processing of time sensitive authorization and pre-certification requests to meet department timeframes and regulatory requirements; Computer Input: Accurately and completely processing referrals/authorizations and distribute a complete file to UM Specialist within 2 hours of receipt; identify duplicate requests using the claims and verify existing authorization. Independently identifying and appropriately returning to claims or member services any file that is a duplicate to one already processed in the system; appropriately documenting what information was used in making this determination within 4 hours of receipt. Appropriate identification and timely notification of time sensitive requests; appropriately identifying for the staff which you support, request that are priority based on date of receipt and established Turnaround Time criteria for compliance. Accurate filing/maintenance of confidential member information. Creating secure, complete, files. Interface with members, medical personnel and other internal and external agencies; ensure all comply with L.A. Care requirements such as submitting requested information in a timely manner and using the approved Authorization Request form with complete medical information i.e.: ICD 10 codes, CPT, HCPC codes. (35%)</div>
<div></div><div>Assist in the preparation of communication for authorization determinations, including, but not limited to preparing template letters for members and providers (authorization approval, denial, deferral, modification and pay/education). (30%)</div>
<div></div><div>Assist in the technical aspects of the retrospective review process for authorizations and Member or Provider Appeals, including, but not limited to computer data entry, logging, copying, preparing of template letters for communication of appeal determinations to members, providers and partners (appeal uphold or overturn) and filing: Set up GNA files for review, log and keep track all due dates for each file. Inform nurses of a new case received from Grievance and Appeals Specialist.; submit all Grievances and Appeals response letters to Grievances Specialist on daily basis. (20%)</div>
<div></div><div>Support UM Committee and Audit activity via Department performance reporting. Assure the accuracy of reports concerning inventory and department proficiency in maintaining regulatory standards and time frames. (5%)</div>
<div>Perform other duties as assigned. (10%)</div>
</div></div><div><div><div>
Duties Continued</div>
</div></div><div></div><div><div><div>Education Required</div>
</div><div><div>High School Diploma/or High School Equivalency Certificate</div></div></div><div><div><div>
Education Preferred</div>
</div></div><div></div><div><div><div>Experience</div>
</div><div><div><b>
Required:</b></div>
<p>At least 6 months of health care experience.</p><br>
<p></p>
<p>Experience working in a cross functional work environment.</p><br>
<p></p>
<p><b>Preferred:</b></p>
<p>Experience in Medi-Cal managed care.</p><br>
<p></p>
<p>1 year of experience in UM/Prior Authorization.</p>
</div></div><div><div><div>
Skills</div>
</div><div><div><b>
Required:</b></div>
<p>Demonstrated proficiency in Medical Terminology required.</p><br>
<p></p>
<p>Strong verbal and written office communication skills.</p><br>
<p></p>
<p>Proficient with Microsoft Office Suite and Adobe PDF. and</p><br>
<p></p><p>Excellent organizational, interpersonal and time management skills.</p><br>
<p></p><p>Must be detail-oriented and an enthusiastic team player.</p><br>
<div></div>
<div><b>Preferred:</b></div>
<p>Knowledge of QNXT computer systems a plus.</p><br>
<p></p>
<p>Knowledge of the UM patient referral process.</p><br>
<p></p>
<p>Knowledge of member&rsquo;s health plan eligibility.</p><br>
<p></p>
<p>Knowledge of member&rsquo;s benefits coverage.</p><br>
<p></p><p>Knowledge of Health Plan regulations.</p><br>
<p></p>
<p>Knowledge of HMO/UM functions.</p><br>
<p></p>
<p>Knowledge of ICD-10/CPT coding.</p><br>
<p></p><p>Proficient utilizing electronic medical records and documentation programs.</p>
</div></div><div><div><div>
Licenses/Certifications Required</div>
</div></div><div></div><div><div><div>Licenses/Certifications Preferred</div>
</div><div><div>Medical Coding Certification</div></div></div><div><div><div>
Required Training</div>
</div></div><div></div><div><div><div>Physical Requirements</div>
</div><div><div>Light</div></div></div><div><div><div>
Additional Information</div>
</div><div><div><b>
Required:</b></div>
<div>Weekends and holidays hours may be required, as well as OT based on a business need.</div>
</div></div></div><div><b>
Salary Range Disclaimer:</b> The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.</div><br>
<div></div>
<div><b>L.A. Care offers a wide range of benefits including</b></div>
<ul><li>Paid Time Off (PTO)</li>
<li>Tuition Reimbursement</li>
<li>Retirement Plans</li>
<li>Medical, Dental and Vision</li>
<li>Wellness Program</li>
<li>Volunteer Time Off (VTO)</li></ul><div><br>
</div></div></div></div></div><p><br>
<b>Nearest Major Market: </b>Los Angeles
<br>
<b>Job Segment: </b>EMR, Claims, Data Entry, Medical Coding, Healthcare, Insurance, Administrative</p></div></div></div><div></div>

Authorization Technician II

Asante

<p></p><div><div><div><p><b>Req #:</b> 24661<br>
<b>Entity:</b> Asante Rogue Regional Medical Center<br>
<b>Location:</b> Medford OR<br>
<b>Department:</b> Case Management<br>
<b>Shift:</b> Variable Schedule Days<br>
<b>Union Position:</b> No<br>
<b>FTE:</b> 0.000001<br>
<b>Schedule:</b> On Call<br>
<b>Salary:</b> $23.28 - $32.02 depending on qualifications</p></div><p></p><div><div><br>
</div></div></div><div><p><b>Description</b>
</p><p><b>Additional Position Details: FTE: 0.000001 | On Call | Variable Schedule Days</b></p><p><b>
Starting Wage</b>: $23.28-$32.02 per hour, depending on experience</p><p></p><p><b>
Position Summary</b></p><p>
The <b>Case Management Specialist </b>functions as a member of the Case Management team. They utilize communication, organizational, and problem-solving skills to carry out the post-hospital care plans and interventions, utilization review, and denials management activities as defined by the RN Discharge Coordinator and RN Utilization Reviewer. They assume a pivotal role with the patient care team to achieve optimal clinical and resource outcomes.</p><p></p><p><b>
Position Qualifications</b></p><p><b>
Experience</b></p><p></p><ul><li>
3 years of experience in administrative functions in care coordination and/or utilization management in healthcare settings is required.</li><li>
Experience with Microsoft Word and Excel is required</li><li>
Experience with EPIC is preferred</li><li>
Current understanding of CMS regulations related to hospital discharge requirements is preferred.</li></ul><p><b>
Education</b></p><p></p><ul><li>
High School Diploma, GED, or equivalent experience demonstrating the ability to effectively communicate as required for the position is required</li><li>
An Associate's degree in business, healthcare administration, or a related field is preferred</li></ul><p><b>
Total Rewards</b></p><p></p><p>
We offer a comprehensive Total Rewards package designed to support your well-being and professional growth, including:</p><p></p><ul><li><b>
Competitive Pay: </b>Hourly and salaried positions earn market-based compensation.</li><li><b>
Health &amp; Wellness: </b>Medical, dental, and vision coverage for part-time and above employees and their eligible dependents beginning within 30 days of hire.</li><li><b>
Retirement Savings: </b>Employer-sponsored retirement plan with company contribution and match.</li><li><b>
Paid Time Off: </b>Generous ETO for part-time and above employees.</li><li><b>
Professional Development: </b>Continue to enhance your education through our tuition reimbursement and tuition repayment program</li><li><b>
Additional Benefits: </b>Life insurance, disability coverage, and employee assistance programs.</li></ul><p></p><p>
At Asante, we are guided by our values:</p><p><b>
Excellence - Respect - Honesty - Service - Teamwork</b></p><p></p><p><i>
Asante is proud to be an Equal Opportunity Employer. We are committed to creating a diverse and inclusive workplace and to employing and advancing qualified individuals of all backgrounds, including women, minorities, individuals with disabilities, and protected veterans.</i></p></div></div><p></p>

Case Management Specialist

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