As a patient-focused organization, University of Utah Health exists to enhance the health and well-being of people through patient care, research and education. Success in this mission requires a culture of collaboration, excellence, leadership, and respect. University of Utah Health seeks staff that are committed to the values of compassion, collaboration, innovation, responsibility, integrity, quality and trust that are integral to our mission. EO/AA

This position is responsible for assisting with the coordination of utilization review, concurrent review and medical necessity review. Provides customer service and interaction with providers and members. This position is not responsible for providing care to patients.

Corporate Overview: The University of Utah is a Level 1 Trauma Center and is nationally ranked and recognized for our academic research, quality standards and overall patient experience. Our five hospitals and eleven clinics provide excellence in our comprehensive services, medical advancement, and overall patient outcomes.

Essential Functions

• Receives requests for prior authorization, concurrent review, post service, or a claim review, and enters the request in the Utilization Management Platform.
• Checks eligibility, network status, procedure coverage, prior authorization status, and obtains clinical records in order to prepare authorization for RN or MD review.
• Communicates the authorization determination to the requestor and/or member.
• Answers and/or responds to calls from operational phone queues.
• Assists providers and members by confirming benefits, verifying member eligibility, quoting prior authorization status and answering questions about prior authorizations.
• Ensures timely notification of decisions to members and providers by fax, mail and telephone.
• Facilitates Utilization Management processes with Medical Review Officers, UM Nurses, hospitals, physicians and other various internal and external customers.
• Maintain understanding of business rules and regulatory requirements pertaining to UM processes and operations.
• Other duties as assigned for preservice, concurrent review, post service and claim reviews.

Knowledge / Skills / Abilities

• Demonstrated potential ability to perform the essential functions as outlined above.

• Demonstrated human relations and effective communication skills.

• Demonstrated computer literacy.

• Ability to handle highly sensitive and confidential issues in a professional manner.

• Ability to prioritize and organize tasks.

Required

• Two years of health care experience or education equivalency.
• Understanding of medical terminology.
• Previous experience in a utilization review setting.

Preferred

• Bachelor's degree in a health-related discipline, business, or the equivalency.
• Coding (CPT, ICD-10, HCPCS and hospital billing codes).

Working Conditions and Physical Demands

Employee must be able to meet the following requirements with or without an accommodation.

• This is a sedentary position that may exert up to 10 pounds and may lift, carry, push, pull or otherwise move objects. This position involves sitting most of the time and is not exposed to adverse environmental conditions.