Insurance Utilization Review Jobs in Portland, OR

Summary of Duties

Pay Range: $27.45/hr to $38.69/hr

The Care management Discharge Coordinator, working as a member of the interdisciplinary team, provides assistance and support to the Case Management team. Helps facilitate a safe discharge plan, providing patients with services and resources as appropriate. Collaborates with the treatment team and the patient to create an appropriate plan based on the resources available. Activities are related to discharge plan coordination, insurance utilization to ensure hospitalizations are covered as well as external resources for discharge and general support of the department employees.

KEY RESPONSIBILITIES

Performed majority of the time:

         Aids Case Management clinical team members in securing necessary post-acute care, DME, community resources and transportation for the various discharge needs of patients.

         Coordinates communication with physicians, clinics, community resources, patients and Case Managers regarding the continuum of care according to determined care plans.

         Provides timely and accurate information to payors, service partners, staff, patients and their families.

         Supports the coordination of utilization management, and discharge planning functions. Assists in discharge planning and coordinate placement of the patient.

         Researches and negotiates patient needs or other resources during discharge process.

         Communicates with third party payer case management and provides documentation as required.

         Collaborates with patients, families, physicians, nurses, and other health care professionals to facilitate post-hospitalization health care services.

         Assists in securing prior authorization from patient's insurance provider for transition to level of care as deemed clinically appropriate to meet level of care needs.

         Discusses payer criteria and issues, on a case-by-case basis, with clinical staff and follows up to resolve problems with payors as needed.

         Determines the need for discharge planning resources within one (1) business day of being flagged for intervention.

         Supports RN Case Manager with execution of an individualized discharge plan that incorporates contributions from the multidisciplinary care team and addresses the discharge needs of patients along the continuum of care for the best possible outcomes.  

         Facilitates the timely discharge of patients from the hospital setting from the discharge coordinator role perspective.

         Seeks consultation from appropriate disciplines/departments as required to expedite care and facilitate discharge.

         Collaborates directly with Case Manager to facilitate appropriate discharge of patient.

         Facilitates referrals for home health care, hospice, medical equipment and supplies and transfer to other facilities as appropriate.

         Documents relevant discharge planning information in EMR according to department standards including all services arranged, referrals and continuous updates.

         Arrange or identify follow up appointments post-discharge including new, PCP, Specialties, lab, radiology etc. to prevent hospital readmissions.

         Provides motivated assistance in admissions, transfers, and discharges of patients managed by Case Management.

         Follow up with any services arranged such as referrals/insurance companies to ensure resources are obtained.

         Arranges patient transportation at the direction of clinical staff.

         Advocates and respects patients' rights and/or significant other's rights.

         Consults with the social worker to identify appropriate social service needs, and help facilitate referrals to appropriate outpatient services.

Utilization Management

o   Reviews Admitting/IVS comments in EMR, approved length of stay, clinical review due date, and insurance company UR contact information in Payer Communication of EMR to minimize miscommunication when coordinating resources

o   Calls appropriate inside or outside personnel to locate missing authorization numbers, approved length of stay, clinical review due date, and insurance company UR contact information to ensure resources are covered for post-acute coordination

o   Collects and organizes data related to clinical condition and treatment plan for use in utilization review by communicating with insurance providers. If denied, collaborates with treatment team to create a new plan.

o   Faxes clinical information to third party payers, when allowed by payer, in order to obtain authorization for continued stay and discharge resources.

o   Notified Case Manager when phoned clinical information is required otherwise, resources are determined and coordinated based on coverage.

Performed occasionally but critical to successful performance of the job:

         Assists in the collection and reporting of resource and financial indicators including, delays, resource utilization, denials and appeals. Supports continuous improvement in these areas.

         Relates pertinent information to Case Management Manager to escalate appropriately and represent to medical committees, nursing staff, and ancillary provider staff as appropriate.

         Maintains up-to-date working knowledge and functional use of Medicare rules and commercial payer rules.

         Manage resource guides to be utilized for the discharge planning process and serves as the single point of contact for external vendors, insurances and care team members.

         Attends all scheduled department meetings.

Decision making and budget responsibilities:

         Decisions can impact the entire unit.

         Supports the manager with data for budget planning.

Hiring Competencies

JOB SPECIFICATIONS

Education:

Required

         N/A

Preferred

         Bachelor's degree in a healthcare related field.

Experience:

Required

         Two (2) years healthcare delivery system related experience.

Preferred

         Discharge planning, utilization review, case management or healthcare insurance experience.

Licenses, Certifications and/or Registrations:

Required

         N/A

Preferred

         Current Oregon license as an LPN, C.N.A. II or Medical Assistant.

Job Related Skills, Abilities and Behaviors:

Required

         Utilizes conflict resolution skills as necessary to ensure timely resolution of issues.

         Collaborates with multidisciplinary care team to eliminate barriers to efficient delivery of care in the appropriate setting.

         Demonstrates an understanding of insurance payor language and various health care options.

         Utilizes problem-solving techniques consistently to resolve complaints or concerns.

         Demonstrates respect of others, communicates clearly and attempts to resolve interpersonal conflicts.  

         Develops and maintain collegial relationships with other professionals by attending continuing education and professional group sessions.

         Demonstrated ethical commitment to quality assurance and confidentiality of all data and information, including HIPPA/PHI.

         Excellent customer service, verbal/written communication and interpersonal relations skills to respectfully serve customers of diverse backgrounds and preferences. This includes the skills to obtain and interpret information appropriate to patients' needs, age, etc. as required for assessment, range of treatment and patient care.

         Familiar with computer word processing, database and spreadsheet programs.

         Demonstrated ability to take initiative, implement and follow through with attention to detail, with minimal supervision.

         Creative problem-solver, solution-oriented, able to stay flexible and professional under the pressure of multiple demands.

         Acts as a team member and supports the success of others.

         Works collaboratively and maintains active communication with the multi-disciplinary care team to effect timely, appropriate patient management.

         Proactively identifies and resolves delays and obstacles to discharge.

         Collaborates, communicates with, and provides support to the multidisciplinary team through all phases of the discharge planning process, including initial patient assessment, planning, implementation, interdisciplinary collaboration, and ongoing evaluation.

         Collaborates/communicates with external case managers and community services.

         Demonstrates confidentiality according to PHI regarding patient and co-worker information.

Preferred

         Knowledge of community health and social service resources.

         Bilingual skills a plus.

Additional Posting InformationHillsboro Medical Center believes in providing equal employment opportunities for all qualified individuals. Recruitment, hiring, promotions, transfers, working conditions, training, and compensation will be based on qualifications without regard to race, color, sex, sexual orientation, gender identity, religion, age, creed, national origin, marital status, family relationship, veteran status, genetic information, physical or mental disability, or any other status or characteristic protected by applicable law. We further commit ourselves to continuing the practical application of this policy in our daily business conduct.Employment Type: OTHER