The Utilization management nurses role is to ensure that health care services are administered with quality, cost efficiency, and within compliance. By continuously reviewing and auditing patient treatment files, the utilization nurse will ensure that patients won’t receive unnecessary procedures, ineffective treatment, or unnecessarily extensive hospital stays.

Job Duties and Responsibilities:

• Concurrent review of patient’s clinical information for efficiency
• Ongoing review of precertification requests for medical necessity
• Monitor the activities of clinical and non-clinical staff
• Coordinates patient’s discharge planning needs with the healthcare team
• Employ effective use of knowledge, critical thinking, and skills to:
  • Advocate quality care and enhanced quality of life
  • Prevent patient complications during hospital stay
  • Advocate decreased hospital stay when appropriate
• Maintain accurate records of all patient related interactions
• Prepare monthly patient management and cost savings report
• Work in an intensive, fast-paced environment with minimal supervision
• Ability to stay organized and interact well with others in any situation
• Provide daily updates to Manager of Utilization Management for review

Skills and Qualifications:

• Bachelor’s degree in Nursing
• State licensure as a Registered Nurse (RN)
• Minimum 2 years of prior experience in Utilization Management
• Strong knowledge of word processing and spreadsheet computer programs
• Utilization Management or Case Management certification preferred
• Basic Life Support certification preferred. Must obtain within 60 days of hire if not currently certified.

Collection representatives will notify patients of delinquent accounts by mail or telephone and ensure timely and accurate payments. Representatives will also demonstrate exceptional customer service to patients, insurance carriers, and healthcare professionals.

Job Duties and Responsibilities:

• Contact patients daily to try and resolve outstanding balances
• Contact patients, physician’s offices, or insurance carriers to expedite claims process
• Resolve insurance or patient issues that result in the patient being billed incorrectly
• Maintain accurate and detailed records of steps taken to resolve outstanding debt
• Maintain all patient demographic information and data in collection systems

Skills and Qualifications:

• High school diploma or GED required
• Minimum one year experience in handling reimbursement or medical/insurance billing preferred
• Ability to multitask with the computer and phone while collecting patient data
• Minimum one year experience using Microsoft Excel, Outlook, and Word
• Advanced verbal, written communication, and organization skills
• Ability to work in high pressure, fast paced environment
• Ability to navigate computers and other office machines

The coder is responsible for reviewing, analyzing, and assuring that the final diagnoses and procedures determined for a patient is valid and complete. To assist physicians with understanding the best treatment for a specific patient, the coder assigns coding or appropriate diagnostic or procedure code to the patient’s records. The coder will ensure proper completion of Electronic Health Records and proper assignment of ICD-9, HCPCS, CPT and all other relevant codes.

Job Duties and Responsibilities:

• Audits submitted records to ensure proper billing of pre-determined charges
• Receives hospital information to properly bill provider services for hospital patients
• Supplies correct ICD-9 codes on all diagnoses provided
• Supplies correct HCPCS and CPT code on all procedures and services performed
• Train care providers on updated and correct coding information
• Audits medical records to ensure proper coding and compliance with federal and state laws
• Ensures the final diagnoses and procedures used by health care providers are valid and complete

Skills and Qualifications:

• High School Diploma
• Medical Coding Certificate – CPC certification is required
• One year experience using ICD-9-CM, CPT, HCPCs or equivalent
• Excellent interpersonal skills
• In depth computer knowledge
• Advanced verbal, written communication, and organization skills

The billing clerk is responsible for compiling the amounts owed to medical providers. The clerk will use data provided by medical coders and submit claims to the insurance companies prior to billing patients. The billing clerk will also record journal entries, communicate any billing adjustment to patients, and more.

Job Duties and Responsibilities:

• Work with insurance companies, healthcare providers and patients to accurately process claims
• Submit claims to insurance companies using coded data
• Appeal and review denied or unpaid claims with insurance companies
• Verify patients’ insurance coverage and answer any subsequent billing concerns
• Attempt to collect outstanding debt on delinquent accounts
• Manage receivables and Medicare bad-debt reports

Skills and Qualifications:

• High school diploma or GED required
• One year experience in handling billing and account receivables reports in a similar or related field
• Some knowledge of CPT and ICD 9 codes preferred
• Advanced verbal, written communication, and organization skills
• Ability to work in high pressure, fast paced environment
• Ability to navigate computers and other office machines
• Basic bookkeeping and accounting knowledge preferred