Sanford Health Utilization Management Coordinator | Utilization Management in Sioux Falls, South Dakota
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Facility: Central Patient Building
Location: Sioux Falls, SD
Shift: 8 Hours - Day Shifts
Job Schedule: Full time
Weekly Hours: 32.00
Monitors the utilization of resources, risk management and quality of care for patients in accordance to established guidelines and criteria for designated setting and status. Collection of clinical information necessary to initiate commercial payor authorization. Obtain and maintain appropriate documentation concerning services in accordance to reimbursement agency guidelines. Consult with interdepartmental departments and staff to assure all relevant information regarding patient status and diagnosis are accurately reported. Provide information via multiple sources of technology applications to insurance companies and contracted vendors to assure authorization for patients. May participate in providing assistance in financial aid and/or counseling if applicable.
Accurately recognizes coding principle diagnosis and principle procedures including complicating/comorbid diagnoses for accurate diagnosis-related group (DRG) assignment during hospitalization. Monitors patient hospitalization to ensure prospective payment limit is not exceeded without due notice to the attending physician. May also need to notify physician and patient of authorization denials. Inputs collected data into computer system for insurance communication, DRG grouping, data abstraction for monitoring and evaluation, and when applicable, Medicare National and Local Coverage Determinations (NCD/LCD), and Joint Commission (TJC) required functions and credentialing. Assists medical records coding personnel as needed to correctly identify diagnoses and procedures, and obtains physician documentation as needed. Monitors patient hospitalization to ascertain medical necessity and appropriateness. Assists with retrospective review of specified charts as required.
Ability to interact on an interpersonal basis with both providers and nursing staff. Demonstrates proficiency with computers, Microsoft applications, and additional designated technology within the department. Will perform multiple administrative duties including accurate record keeping and electronic data management when needed. Ability to work with growth and development needs of pediatric to geriatric populations.
Appropriate education level required in accordance with licensure.
Seven years of relevant experience, superior communication and interpersonal skills. Minimum one year healthcare or clinical experience required.
Specific background or experience in healthcare reimbursement, insurance industry, and/or authorization experience would be critical to the success in this role and preferred.
Currently holds an unencumbered Licensed Practical Nurse (LPN) license with State Nursing board and/or possess multi-state licensure privileges, or Registered Health Information Technician (RHIT) required. Additionally, coding certifications also acceptable, i.e. Certified Coding Specialist (CCS), Certified Coding Specialist - Physician based (CCS-P), Certified Professional Coder (CPC), Certified Professional Coder - Hospital (CPC-H), Certified Outpatient Coder (COC), or Certified Ambulance Coder (CAC).
Obtains and subsequently maintains required department specific competencies and certifications.
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Job Function: Care Coordination
Req Number: R-19388