Utilization Review Tech I

Join an award-winning team of dedicated professionals committed to our core values of quality, compassion and community! Roxborough Memorial Hospital, a member of Prime Healthcare, offers incredible opportunities to expand your horizons and be part of a community dedicated to making a difference.

Roxborough Memorial Hospital is a 131-bed community hospital. The hospital has been serving the medical and health care needs of the Roxborough, Manayunk, East Falls and northwest section of Philadelphia communities for more than a century, having first opened its doors in 1890. Roxborough Memorial Hospitals School of Nursing has been educating nurses since 1898. The hospital is accredited by the Joint Commission on the Accreditation of Healthcare Organizations, the nation's oldest and largest hospital accreditation agency.

Company is an equal employment opportunity employer. Company prohibits discrimination against any applicant or employee based on race, color, sex, sexual orientation, gender identity, religion, national origin, age (subject to applicable law), disability, military status, genetic information or any other basis protected by applicable federal, state, or local laws. The Company also prohibits harassment of applicants or employees based on any of these protected categories. Know Your Rights: https://www.eeoc.gov/sites/default/files/2022-10/EEOC_KnowYourRights_screen_reader_10_20.pdf

The Utilization review tech essentially works to coordinate the utilization review and appeals process as part of the denial management initiatives. Utilization review tech is responsible for coordinating phone calls, data entry and tracking data from various insurance providers and health plans regarding authorization, expedited reviews and appeals. Document and track all communication attempts with insurance providers and health plans. Utilization review tech will follow up on all denials while working closely with the Corporate/Facility Utilization review teams, Business Office and Case Managers. The Utilization review tech will also serve as the primary contact and coordinate the work to maintain integrity of tracking government review audits (RAC, MAC, CERT, ADR, Pre/Post Probes, QIO/Medicaid) and other payer audits as assigned. The Utilization review tech will further support the department needs for Release of Information, discharge coordination or other duties as assigned.

Education and Work Experience

1. Minimum one year denials management experience in acute care setting highly preferred.
2. High School Diploma or equivalent required.
3. Accurate alphabetic, numeric, and/or terminal-digit filing skills.
4. Computer data entry with 10-key, with accurate typing speed of 35 wpm required. Excel skills highly preferred.
5. Knowledge of terminal digit filing and medical terminology; preferred.
6. Knowledge of State and Federal regulatory requirements for medical staff documentation; preferred.
7. Completion of a medical terminology course; preferred.
8. Background in business and office training; preferred.