Utilization Review Coordinator Lead
Umpqua Health
Full Time - Regular
Roseburg, OR, US
POSITION PURPOSE
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The Utilization Review Coordinator, Lead Level 3 will provide leadership and instruction to others in the UHA group to complete tasks quickly and effectively. Performs clinical reviews for Umpqua Health Alliance (UHA) to determine the medical necessity of requested services based on applicable Medicaid/Medicare policies and criteria. The URC will adhere to regulatory compliance requirements, department quality metrics and provide exceptional customer service to all internal and external customers.
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ESSENTIAL JOB RESPONSIBILITIES
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- Provide leadership for our Utilization Coordinators who provide review under Utilization Management.
- Assist in the development of Utilization Management programs to meet the strategic initiatives of UHA Services.
- Assist in the selection, training, evaluation, and development of professional paraprofessional, and administrative team members.
- Lead Utilization Management teams in effective performance of job functions, which may include preauthorization, outpatient and inpatient management, case management, retrospective claim review, and delegated management oversight.
- Participate with management in the development and monitoring of budgets in accordance with department and organizational objectives.
- Assist with the adjustment and direction of work processes to support cost and utilization variations.
- Provide guidance to answer questions, offer insight and organize responsibilities.
- Participate in the development, implementation, and monitoring of the department's performance standards, utilizing quality improvement methodologies to refine procedures.
- Participate in the establishment and implementation of Utilization Management policies as required.
- Foster collaborative work environment that encourages team building, facilitates cohesive synergetic performance of Utilization Management functions, while valuing the individual diversity and uniqueness of all employees.
- Participate in Total Quality Management activities and processes to assure operational compliance with regulatory requirements.
- Review actual and proposed medical care and services compared to established guidelines.
- Maintain updated knowledge of the Oregon Administrative Rules (OAR) governing the Oregon Health Plan as well as all applicable Medicare guidelines. Referring to DMAP/ Medicare websites as needed. This includes the understanding of the policies and procedures that apply to the Appeal and Grievance process and the Members Rights and responsibilities as stated by the Division of Medical Assistance Program (DMAP) as well as CMS.
- Demonstrate an ongoing understanding and current knowledge of benefits for OHA/Medicare.
- Understand and participate in the prior authorization process for procedures, durable medical equipment, admits, referrals and transfers to Skilled Nursing Facilities (SNF) and out-of-area admissions within allotted timeframes.
- Work together with the Third-Party Recovery (TPR) coordinator regarding any member with the potential for additional insurance coverage as well as reporting any case that may reach stop loss.
- Work with Member Services department with eligibility issues including when a member has a change in address or moved out of area.
- Make appropriate referrals to Care Coordination and Behavioral Health.
- Consult with Medical Director as needed.
- Train new and cross departmental staff as well as assist leadership with onboarding procedures.
- Conduct audits and other investigatory activities to identify and rectify process improvement opportunities.
- Work collaboratively with claims and provider networking department to problem solve and communicate with internal and external stakeholder of changes or improvements in processes. This include developing educational materials to be managed on the UHA website, provider newsletter, talking points and department trainings.
- Assist manager and director with administrative support tasks, such as meetings, employee engagement opportunities and communications.
Lead Duties include but are not limited to:
- Management and use and maintenance of HRIS as needed to perform basic supervisory duties, pto requests, leaves, timecards.
- Participation in interviews, evaluation of staff and new-hire onboarding practices.
- Staff coaching and performance management as needed.
- Complexity of duties may vary based on the level of experience, education and qualifications of specialist.
- Oversee the team including but not limited to;
- In collaboration with Manager, ensure staff have daily huddle for new tasks and updates and complete assigned tasks
- Communication to all team if staff calls out of what the coverage will be.
- Ensuring all team are current with workload, including empty voicemail boxes at the end of the business day.
- Assign extra duties to staff when needed to fulfill needs of department.
- Ensure all patient calls are returned by end of business by all staff
- Working collaboratively with leadership and staff to ensure efficient, system wide processes are in place.
- Create and update Standard Operating Procedures for staff
- Make recommendations and assist with department Policies as assigned by Managers.
- Understand CCO regulations with OHA contract.
- Other duties as assigned.
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GUIDING BEHAVIORS
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Accountability
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Always demonstrate the highest performance and behavior standards. Share responsibility and expect others to be accountable.
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Efficiency
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Demonstrate a proactive approach to problem identification and solutions. Be innovative and solutions oriented, improving processes while reducing costs. Demonstrate appropriate time-management skills. Optimize the use of available resources.
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Be a Team Player
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Support and assist your team members. Be available to help and learn from your team. Keep an open mind to feedback and earn trust of staff. Identify your teams strength and weakness. Evaluate goals and give a clear understanding of what is expected in achieving those goals.
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Integrity
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Keep your promises, commitments, and confidences. Be honest and straightforward in communicating and dealing with all issues fairly and consistently. Be a good listener and give appropriate constructive feedback.
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Stewardship
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Adhere to all state and federal regulations relating to your position including the Health Insurance Portability and Accountability Act (HIPAA), Fraud & Abuse and Occupational Safety and Health Administration (OSHA) laws. Abide by Company policies and procedures at all times.
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CHALLENGES
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- Working with a variety of personalities, maintaining a consistent and fair communication style.
- Working in a fast-paced environment with shifting priorities.
- Coordinating resources to achieve goals and objectives.
- Remote/work from home: Must have a separate room with a locked door that can be used as a home office to ensure you and your patients have absolute and continuous privacy while you work.
- Must have the ability to provide a high-speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 10x1 (10mbs download x 1mbs upload) is required.
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QUALIFICATIONS
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- Level 3: Current RN, LPN, RT, LCSW, LPC, LMFT, Licensed Psychologist or equivalent license with 10 years experience with varied medical and/or behavioral health exposure and capability required. CACD I and higher for Behavioral Health position(s).
- Experience in acute care, case management, including cases that require rehabilitation, home health, behavioral health and hospice treatment required.
- Leadership experience including staff management and the ability to mentor and train.
- Previous utilization review and experience in a managed care setting required.
- Experience following established medical guidelines required.
- Clinical knowledge of the health or social work needs for the population served.
- Demonstrated ability to identify barriers to a successful care management path.
- Ability to interact effectively and professionally with internal and internal customers.
- Proficient PC Navigational skills required; solid data entry and MS Office skills required.
- Excellent critical thinking and time management skills.
- Excellent written, verbal and interpersonal communication skills, with demonstrated ability to provide exceptional customer service to internal and external customers.
- Demonstrated transferable knowledge, skill and ability to complete job duties independently and proficiently.
- Current Oregon Drivers license required.
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PHYSICAL DEMANDS
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Typical office environment requiring standing, sitting, walking, bending, and lifting up to 25 pounds.
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PI174009281
Categories
Posted: 2022-04-15 Expires: 2022-05-16
