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Utilization Review Specialist III

2 months ago

Ontario, California, United States Prime Healthcare Full time
Overview

Prime Healthcare is a prestigious healthcare organization based in Ontario, California.

With a network of 45 hospitals and over 300 outpatient facilities across 14 states, Prime Healthcare serves more than 2.6 million patient visits each year.

As one of the leading health systems in the nation, we employ nearly 50,000 professionals, including healthcare providers. Fourteen of our hospitals are affiliated with the Prime Healthcare Foundation, a 501(c)(3) nonprofit public charity. We are currently seeking dedicated individuals to enhance our corporate team.


We are an Equal Opportunity Employer and do not discriminate against applicants based on veteran status, disability, race, gender, gender identity, sexual orientation, or other protected characteristics.

If you require special accommodations during the application process, please reach out to Human Resources.

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Responsibilities


The Utilization Review Technician III plays a crucial role in managing the utilization review and appeals process as part of our denial management strategies.

This position acts as a liaison, coordinating efforts with other UR technicians while overseeing phone communications, data entry, mailing/faxing appeals, and tracking information from various insurance providers and health plans regarding authorizations, expedited reviews, and appeals.

Documenting and tracking all communication attempts with insurance providers and health plans is essential, along with scanning all related correspondence into the respective EMR/tracking tool.

The Utilization Review Technician III will follow up on all denials, collaborating closely with the Corporate/Facility Utilization Review teams, Business Office, and Case Managers.

This role also serves as the primary contact for maintaining the integrity of tracking government review audits (RAC, MAC, CERT, ADR, Pre/Post Probes, QIO/Medicaid) and other payer audits as assigned.

As a Subject Matter Expert (SME), the UR Technician III will support the UR technician team and remote counterparts with specific processes as needed.

Additionally, this position will assist the department with Release of Information tasks through faxing and mailing, discharge coordination, or other assigned duties.

Qualifications

Required qualifications:
- Bachelor's degree or four years of relevant experience required.
- Proficiency in Microsoft Office.
- Strong communication skills.

Preferred qualifications:
- Completion of a medical terminology course is preferred.
- Knowledge of HIPAA regulations is preferred.


We are an Equal Opportunity/Affirmative Action Employer and do not discriminate against applicants based on veteran status, disability, race, gender, gender identity, sexual orientation, or other protected characteristics.

If you require special accommodations during the application process, please contact Human Resources. EEO is the


Prime Healthcare Management Inc. offers competitive compensation and a comprehensive benefits package that allows employees to customize benefits according to their individual needs.

Our Total Rewards package includes, but is not limited to, paid time off, a 401K retirement plan, medical, dental, and vision coverage, tuition reimbursement, and various voluntary benefit options.

A reasonable compensation estimate for this role, encompassing estimated wages, benefits, and other forms of compensation, ranges from $20.00 to $30.00.

The exact starting compensation will be determined at the time of selecting an applicant for hire, considering a wide range of factors, including skillset, years of applicable experience, education, credentials, and licensure.