The Utilization Review Professional, uses decsion trees, standard work and clinical expertice works to obtain authorizations for payment by timely management of cases not paid as expected for any number of reasons including but not limited to LOC authorizations, denials and billing disputes. The Utilization Review Professional analyzes charges, reimbursement and contract information to determines appropriate chart, telphonic and/or written justification and timely transmits the information, as well as, performs any needed follow up required to obtain the authorization. Completes assigned work queues daily by analyzing contracts, authorizations and MD orders and chart documentation using clinical expertise to determine appropriateness of authorizations/payments received. Manages accounts in assigned work queues daily utilizing decision trees, standard work and clinical expertise to pursue authorizations for denials and billing disputes. Analyzes charges, reimbursement and contract information to determine appropriate chart, telephonic and/or written justification. Reviews documentation in the billing system of activities and ensures that authorizations are complete and timely. Performs any needed follow up required to obtain completed authorizations. Other duties as assigned.
4+ years experience as a licensed health care professional in acute medical setting or minimum 2 years of experience as a URA II