Management Utilization Specialist in Fairfax, VA at Washington Radiology

Date Posted: 8/12/2019

Job Snapshot

Job Description

Reports to the Revenue Cycle Manager, Director of Business Office or Director of Revenue Cycle Management. Reviews patient, procedure, and insurance data to identify exams that may require authorization. Contacts managed care organizations (MCO’s), ordering physicians, and patients to facilitate or obtain exam pre-authorization. Reschedules or cancels exams that do not meet MCO guidelines for medical necessity. Works with patients and referral sources concerning alternative arrangements when exams are denied pre-authorization. Advises supervisors on changes to MCO’s requirements for pre-authorization.

II. Duties and Responsibilities

a. Required Knowledge, Skills and Abilities
i. Knowledge of 10-key, typing, personal computers and internet
ii. Ability to understand basic medical coding principles, medical terminology, and, with appropriate training, make proper decisions regarding CPT, HCPCS, and ICD-10 codes as they relate to diagnostic radiology.
iii. Ability to communicate courteously, pleasantly, and effectively with patients, physicians, and related office staff via telephone, in person or email.
iv. Ability to establish and maintain long-term customer relationships, building trust and respect by consistently meeting and exceeding customer expectations.
v. Ability to take direction and then autonomously establish priorities to meet deadlines.
vi. Possess a mature approach to work and the ability to establish and maintain effective working relationships on many different levels.
vii. Good oral and written communications skills
viii. Must be able to handle and utilize various types of office equipment to include multi-line telephone and facsimile machine
b. Essential Functions
i. Verifies insurance benefits and requirements; determines if pre-authorization or prior notification is required.
ii. As needed, contact the MCO’s pre-authorization department (telephonically, via fax, or through its on-line systems) and initiate pre-authorization review; if provided, verifies authorization numbers obtained by scheduling staff, patients, and referring physicians.
iii. Telephonically contacts patients and referring physicians to obtain all necessary account information.
iv. Works with referring physician offices and WR’s clinical facilities to obtain information and relevant documents to substantiate medical necessity; if permitted, provides that documentation to the MCO to expedite pre-authorization processing.
v. Ensures the authorization is for the appropriate CPT codes and treatment facility.
vi. Enters all information and authorization numbers into WR’s patient registration system.
vii. Maintains updated information in WR’s pre-authorization database; generates and disseminates reports concerning the pre-authorization program.
viii. Stay abreast of changes to MCO’s pre-authorization policies; communicates these changes to staff and ordering physicians; answers questions and explains pre-authorization policies clearly.
ix. Supports the corporation’s effort to offer pre-authorization assistance to ordering physicians; works closely with clinical offices and marketing department concerning requests for assistance.
x. Maintains confidentiality of records and information.
xi. Displays a positive public image when dealing with patients, referral sources, payers and team members.
c. Additional Requirements:
i. Assist other team members during special projects as directed.
ii. Assist in cross-training of other employees as directed.
iii. Maintains HHS, CMS and HIPAA compliance.
iv. Attends departmental meetings and training courses.
v. Other duties as assigned.


Job Requirements

Requirements and Qualifications

i. High school graduate; medical office training or college course work in healthcare administration desirable.

ii. Two to three years experience in pre-authorization, medical billing, and healthcare collections practice desirable

iii. Experience or knowledge of diagnostic radiology desirable.