Utilization Review Professional

Title: Utilization Review Professional

Location: Long Beach

Department: OPSC Utilization Mgmt MCH OP

Status: Full-time

Shift: Day

Pay Range*: $43.97/hour - $36.76/hour

MemorialCare is a nonprofit integrated health system that includes four leading hospitals, award-winning medical groups – consisting of over 200 sites of care, and more than 2,000 physicians throughout Orange and Los Angeles Counties. We are committed to increasing access to patient-centric, affordable, and high-quality healthcare; your personal contributions are integral to MemorialCare's recognition as a market leader and innovator in value-based and other care models.

Across our family of medical centers, we support each one of our bright, talented employees in reaching the highest levels of professional development, contribution, collaboration, and accountability. Whatever your role and whatever expertise you bring, we are dedicated to helping you achieve your full potential in an environment of respect, innovation, and teamwork.

Position Summary

The Utilization Review Professional, uses decision trees, standard work and clinical expertise 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, telephonic and/or written justification and timely transmits the information, as well as, performs any needed follow up required to obtain the authorization.

Essential Functions and Responsibilities of the Job

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.

Duties performed meet standard work, department productivity and timeliness requirements.

Other duties as assigned.

*Placement in the pay range is based on multiple factors including, but not limited to, relevant years of experience and qualifications. In addition to base pay, there may be additional compensation available for this role, including but not limited to, shift differentials, extra shift incentives, and bonus opportunities. Health and wellness is our passion at MemorialCare—that includes taking good care of employees and their dependents. We offer high quality health insurance plan options, so you can select the best choice for your family. And there’s more...Check out our MemorialCare Benefits for more information about our Benefits and Rewards.

Minimum Requirements

Qualifications/Work Experience:

4+ years experience as a licensed health care professional in acute medical setting. Or minimum 2 years experience as a URA II.

Education/Licensure/Certification:

AA Degree and a health care license is required.

Schedule: Full-time

Travel:

Shift: Day Job