Position Title: Authorization Care Coordinator (Mon - Fri 8:30a - 5:00p PST)

Remote Position

Reports To: Director, Payer Communications

FLSA Status: Non-Exempt

JOB SUMMARY

The BHU Utilization Review Coordinator will monitor adherence to the hospital’s utilization review plan to ensure the effective and efficient use of hospital services and monitor the appropriateness of hospital admissions and extended stays. The BHU Utilization Review Coordinator will complete TARs, authorizations, clinical appeals, etc. to ensure each day is authorized and has appropriate documentation. Perform various clerical tasks utilizing knowledge of office systems and procedures, facility regulations and interdepartmental functions.

Key Responsibilities:

• Responsible for processing all Treatment Authorization Requests (TAR) in BHU.
• Confirms MediCal TARS are completed for all dates of services and requests follow-up from all disciplines, including clinical writeup as needed.
• Ensures the authorization is present for non-MediCal patients including submitting clinicals, establishing process on proper authorization intake to ensure all days are approved and paid
• Calls and coordinates with all payors on additional documentation needed
• Verify patient admission eligibility.
• Confirm admission criteria are met per Title 22. If the criteria are not met, contact the Admitting Department and unit nurses to make necessary adjustments.
• Submit TARs/Authorizations per State process/Payor request. Upload concurrent TARs to the State twice per week. Submit clinicals to Non-MediCal payors as requested by payor.

ESSENTIAL FUNCTIONS

• Generate monthly PI reports and communicate with providers to fulfill all requirements.
• Follow up authorization from Managed Medicare, private insurance, etc.
• Prepares MediCal appeal decisions involving upheld denied days for further appeal by providing Director of Case Management or Supervisor the original TAR, original adjudication response, appeal letter decision and face sheet for submission to contracted vendor to appeal further.
• Process adjudication responses and appeal decisions form MediCal, upon receipt to Case management, to include date stamp the date received and log all cases decisions on MediCal log.
• Complete date entry in Revenue Cycle on a weekly basis, at least, to verify the status of TARs needed to be completed and status on TARs needing appeals and follows up to process timely.
• Uses clear, concise, professional communication with coworkers, patients, all customers internal and external.
• Establishes and maintains efficient methods of ensuring the medical necessity and appropriateness of hospital admissions.
• Performs concurrent reviews for patients to ensure that extended stays are medically justified and are documented in patient's medical records.
• Acts with a sense of urgency when performing tasks.

Education

Minimum

• High School Diploma

Preferred

• N/A

Work Experience

Minimum

• 2 – 5 years of experience in processing TAR in BHU
• Possesses skills set to provide clerical support to the Utilization Management team.
• Knowledge of Medical terminology required.
• Critical thinking, service excellence and good interpersonal communication skills, ability to read/comprehend written instructions, strong organizational skills, ability to follow verbal instructions, and PC (computer) skills.
• A capacity to learn, synthesize, make critical judgments, work independently, place patients and families first, and collaborate with the team members.
• Ability to work independently in a remote environment with minimal supervision

Preferred

• N/A

Required Skills, Knowledge, and Abilities

• Knowledge of health insurance plans, authorization processes, and payer requirements.
• Strong organizational and time management skills in a fast-paced environment.
• Effective written and verbal communication skills with patients, providers, and payers.
• Proficiency with Microsoft Office, EHR systems, and insurance portals
• Ability to collaborate with clinical and administrative staff while maintaining confidentiality.
• Ability to problem-solve, prioritize, and adapt to changing payer guidelines and workflows.