Resource Utilization Specialist

6 days ago


Evanston, Illinois, United States Prime Healthcare Full time
Job Title: Resource Utilization Specialist

About the Role:
Prime Healthcare is seeking a skilled Resource Utilization Specialist to join our team. As a Resource Utilization Specialist, you will play a critical role in coordinating the utilization review and appeals process, working closely with various stakeholders to ensure seamless communication and efficient decision-making. This position requires strong analytical skills, attention to detail, and excellent communication abilities.

Responsibilities:
- Coordinate phone calls, data entry, and tracking of insurance provider responses regarding authorization, expedited reviews, and appeals.
- Document and track all communication attempts with insurance providers and health plans, scanning related correspondence to the respective EMR/tracking tool.
- Follow up on denials while collaborating with Corporate/Facility Utilization Review teams, Business Office, and Case Managers.
- Serve as the primary contact for maintaining integrity of tracking government review audits (RAC, MAC, CERT, ADR, Pre/Post Probes, QIO/Medicaid) and other payer audits assigned.

Requirements:
- High School Diploma or Equivalent required.
- Microsoft office proficiency necessary.
- Good communication skills essential.
- Preferred qualifications: completion of a medical terminology course; knowledge of HIPAA regulations.

Earnings: Estimated $54,000 - $64,000 per annum, depending on experience.

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