Are you looking for a place where you are empowered to bring innovation to reality? Join MarinHealth, an integrated, independent healthcare system with deep roots throughout the North Bay. With a world-class physician and clinical team, an affiliation with UCSF Health, an ever-expanding network of clinics, and a new state-of-the-art hospital, MarinHealth is growing quickly. MarinHealth comprises MarinHealth Medical Center, a 327-bed hospital in Greenbrae, and 55 primary care and specialty clinics in Marin, Sonoma, and Napa Counties. We attract healthcare’s most talented trailblazers who appreciate having the best of both worlds: the pioneering medicine of an academic medical center combined with an independent hospital's personalized, caring touch.
MarinHealth is already realizing the benefits of impressive growth and has consistently earned high praise and accolades, including being Named One of the Top 250 Hospitals Nationwide by Healthgrades, receiving a 5-star Ranking for Overall Hospital Quality from the Centers for Medicare and Medicaid Services, and being named the Best Hospital in San Francisco/Marin by Bay Area Parent, among others.
Company:
Marin General Hospital dba MarinHealth Medical Center
Compensation Range:
$28.81 - $43.21
Work Shift:
8 Hour (days) (United States of America)
Scheduled Weekly Hours:
40
Job Description Summary:
JOB SUMMARY: Under the supervision of Manager of Care Coordination, the Utilization Management Specialist role performs diversified non-licensed functions to support the Utilization Management Team. The UM Specialist communicates with review organizations, vendors, providers and other external customers to satisfy utilization management functions to ensure patient stays and services are authorized. The UM Specialist updates treatment authorizations, documents clinical denials (concurrent and retrospective) and processes review requests. The UM Specialist collaborates with all members of the care team and documents their activities within the patient record for review.
Job Requirements, Prerequisites and Essential Functions:
JOB SPECIFICATIONS:
A. EDUCATION
High School graduate or equivalent, A.A degree in Business /Health Related field or equivalent experience in a health care setting required
B. EXPERIENCE
Proficiency in medical terminology, Experience in commercial and government insurance, financial counseling or registration
Minimum of 2 years of job-related experience in a health care setting
Proficiency with electronic health record (EHR) and other care management applications i.e., EPIC
C. PREREQUISITE SKILLS
Basic knowledge of medical terminologies Knowledge of medical record documentation application processes Solid communication and interpersonal skills to communicate effectively with all levels of staff verbally and in writing Ability to carry out instruction provided in written or oral Ability to manage, set priorities and operate with minimal direct supervision and can work effectively under pressure
LICENSE/REGISTRATION/CERTIFICATION:
1. None
PRIMARY CUSTOMER SERVED (Age Specific Criteria):
( ) This position is not a patient care position, and as such, this section does not apply.
( ) Infants - Birth up to 1 year
( ) Adolescents - 12 up to 18 years
( ) Toddlers - 1 up to 3 years
( ) Early Adults - 18 up to 45 years
( ) Preschool Children - 3 up to 6 years
( ) Middle Adults - 45 up to 61 years
( ) School - Age Children 6 up to 12 years
( ) Late Adults - 61 up to 80 years
( ) Late, Late Adults - 80 years and up
Employees in this position must be able to demonstrate the knowledge and skills necessary to provide care and/or service based on the physical, psycho/social, educational, safety, and related criteria appropriate to the age of the patients served in his/her assigned service area.
PATIENT PRIVACY (HIPAA Compliance):
( ) Employees in this position do not have access to protected health information.
(x ) Employees in this position have access to protected health information. The protected health information a person in this position can access includes demographics, date of service, insurance/billing, medical record summary information, and all other information that may be contained in patient records. This position requires patient health information to perform the functions outlined as part of this position description.
DUTIES AND RESPONSIBILITIES:
A. ESSENTIAL (not modifiable)
Supports the utilization management process by entering requests for utilization review, authorization of stay for concurrent and post billing denials to support utilization management workflow. Document vendor determination in EPIC to ensure that only approved days are billed. Capturing insurance authorization information and processing that data for billing Coordinates Peer-Peer requests with the insurance medical director and the MHMC provider Securing all Medicare QIO Livanta Medicare discharge appeal notifications and work with the care team to generate and submit appeal packet for processing Link health plan clinical staff with utilization review nurses, and case managers as needed to ensure to ensure patients continue stay is authorized. Documents accurately, thoroughly, and legibly in the medical record. Demonstrates proficiency in use and application of all electronic applications. Ensure that HIPPA guidelines for patient privacy are maintained and highlights any risks identified to leadership. Work with admission and patient’s financial services department to ensure that the correct patient insurance information is assigned to patients’ admission. Answers multiple and /or designated telephone lines, able to prioritize and route calls 12. Prepares denial letters as indicated per department policy and regulatory guidelines. Provides clerical support as needed including copying, faxing and data entry. Collaborates with team members on interdependent tasks. Demonstrates both initiative and flexibility working with Physicians, Utilization review nurses and other staff. Ensures that routine and priority tasks are completed within established departmental time frames. Positively contributes to team decision making process in planning daily priorities, resolving barriers to discharge plans seeking creative solutions.
B. SECONDARY (modifiable)
1.
2.
Reasonable accommodation(s) to qualified individuals with disabilities are available as part of the application step. If an accommodation is needed, please contact Human Resources at 415-925-7040 or email
[email protected]
to initiate the process.
MarinHealth is a diverse community of people with many different talents. We seek candidates whose work experience has prepared them to contribute to our professional, C.A.R.E.S standards (Communication, Accountability, Respect, Excellence, and Safety) . These behavioral standards help us create a healing environment for patients and colleagues alike. By committing to them and holding ourselves accountable, we can build trust and ensure clear communication.
At MarinHealth, our top priority is the well-being of our employees, patients, and community. As such, we require all employees to receive necessary immunizations, including the measles, mumps, varicella, and seasonal flu vaccinations as a condition of employment and annually thereafter. Additionally, the continued recommendation to obtain a COVID + booster vaccination status. We understand that some individuals may require medical or religious exemptions from these requirements, and we remain committed to prioritizing the health and safety of all. Thank you for helping us in our efforts to maintain a healthy and safe environment.
The compensation for this role listed on this posting is in compliance with applicable law. The selected candidate’s compensation will be determined based on the individual’s skills, experience, internal/market equity factors, and qualifications. This posted minimum and maximum range represents the minimum and maximum of what we reasonably expect to compensate for the position. Furthermore, all compensation decisions are ultimately determined in accordance with our compensation philosophy. Compensation for positions covered by collective bargaining agreements are governed by the agreements in the aforementioned document.
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