GENERAL SUMMARY:

Responsible for supporting the Utilization Management team by assisting with obtaining documentation/signatures needed for insurance purposes and the ability to explain the documents to patients in our care. Monitors and records utilization activities of patients under the direction of Utilization Management. Ensures documentation is provided of insurance company requests or determinations. Collaborates in an interdisciplinary manner to optimize patient care, quality reimbursement and regulatory compliance.

PRINCIPAL JOB FUNCTIONS:

1. *Commits to the mission, vision, beliefs and consistently demonstrates our core values.
2. *Understands and operationalizes federal regulations regarding Advance Directives, COBRA, Medicare, Corporate Compliance, Joint Commission, OSHA and HIPAA; reports safety and customer concerns.
3. *Administers and documents appropriate Medicare Outpatient Observation Notice (MOON), Hospital Issued Notices of Non-Coverage (HINN), Advanced Beneficiary Notices (ABN) and other documents as deemed appropriate.
4. *Adheres to current rules, regulations and policies related to the Medicare program, Medicaid program and third party payer guidelines.
5. *Interacts in an interdisciplinary manner and serves as a resource regarding patient's insurance guidelines and requirements.
6. *Routes insurance inquiries to the proper persons and departments.
7. *Assists with Utilization Management functions by participating in concurrent and retrospective denials and appeals processes by researching issues surrounding the denial.

EDUCATION AND EXPERIENCE:

High school diploma or equivalent required. Licensure or certification in a field of medical or allied health area of study preferred. Minimum two (2) years clinical experience preferred.

OTHER CREDENTIALS / CERTIFICATIONS:

Basic Life Support (CPR) certification required. Bryan Health recognizes American Heart Association (for healthcare professionals), American Red Cross (for healthcare professionals) and the Military Training Network.