Utilization Management Spec

1 month ago


New York, United States Goodwill Industries Of Greater New York Full time
Job DescriptionJob Description

Goodwill Industries of Greater New York and Northern New Jersey, Inc.

Position Title: Utilization Management Specialist (Rehab Division)

General Purpose:

Perform day to day operations ensuring all service documentation is in compliance with funding source requirements in order to submit billing claims. Obtain and review documents from outside agencies required for service authorization. Responsible for monitoring client’s eligibility to attend Goodwill programs. Maintain folders / documentation in audit ready condition.

Essential Functions:

· Develop strong working knowledge of funding source/ federal/ state regulations to assist Goodwill’s programs in maintaining compliance. · Verify units of service / billing for each program as determined by the program model (daily, hourly, milestones, etc.) · Review daily services and notes, monthly case notes, and / or other forms of service documentation for accuracy & required elements. · Track client’s eligibility for services and follow up with insurance companies and funder when issues arise. · Run billing and attendance reports in EHR. · Submit billings using web based applications. Track remittance reports and follow up on claims that are denied. · Submit applications for service approval in funders required format (i.e., CHOICES for OPWDD). · Obtain documents necessary for service authorization and billing (i.e., OPWDD ISP, NOD, LOC, and Evaluations; OMH documents as appropriate), scan into EHR, and track expiration dates in database. · Review Service Plans for required billing elements and follow up as necessary. · Track Service Plans, Service Plan meetings, and other monthly events & liaise with Program staff and supervisors. · Review received documents to ensure they meet funders/regulators requirements, request changes as needed. · Review EHR to determine compliance with funders/regulators requirements. · Enter data for new starts in EHR & create paper records as needed. · Deliver staff training in EHR and funding source requirements as necessary. · File documents. · Other duties as requested by supervisor.

Qualifications/Basic Job Requirements:

· BA/ BS in relevant area preferred. HS Diploma / GED Equivalent required. · Prior experience with managed care, Medicaid, or other private insurance funding, or some kind of service billing experience. · Prior experience with people who have disabilities · Prior experience in billing, book keeping, compliance or related field strongly preferred · MUST be detailed oriented, organized, and accurate in highly consistent manner · Ability to work as part of a team in a fast paced environment · Working knowledge of MS Word, MS EXCEL, MS Outlook, and Internet required.

Scope of Responsibility & Positions Supervised:

· Will oversee day to day operations with funding source billing and quality requirements for a variety of programming. Works in conjunction with a team of Billing Specialists and Supervisor / Manager. Supervised by Supervisor, Program Manager, or Division Director dependent on program funding / structure.

Special Working Conditions:

Travel to various program sites may be required



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