E00980 – Utilization Review Coordinator – MAT
Position Overview: Under the supervision of the Director of Operations and in working closely with the Executive Directors at each MAT location, the MAT Utilization Review Coordinator manages utilization and authorization of patient care in RCA MAT programs. Primarily, the MAT Utilization Review Coordinator is responsible to secure authorization for funding of MAT related services including methadone maintenance, OBOT, group and individual therapy, IOP, and any other billable services that the RCA MAT sites are licensed to provide. This includes obtaining authorization for payors in which RCA is not in network and collaborate with the Managed Care and Patient Accounts Department to secure appropriate single case agreements. Additionally, he/she will ensure documentation aligns with RCA procedures and protocols, regulations of the state, and accrediting bodies. The MAT Utilization Review Coordinator is responsible for reviewing medical records and communicating missing components required by RCA, payor, or regulatory standards to the clinical and medical leadership teams and follow up to verify appropriate documentation is filed. The MAT Utilization Review Coordinator will review, understand, and communicate all insurance standards to determine criteria concerning admissions, treatment, and length of stay. The MAT Utilization Review Coordinator must always act as an advocate for extending patient treatment to support the clinical treatment plan and provides education to clinical team surrounding medical necessity criteria. Ensures any insurance denials are communicated to treatment team immediately and manages any appeals to expedite coverage for appropriate level of care. The MAT Utilization Review Coordinator will be responsible to work closely with the patient accounts and managed care teams to resolve payor or unbilled issues, acting as a liaison between the site level leadership and supports in the corporate office.
- Works closely with insurance carriers to provide accurate information and obtain authorization of coverage.
- Enters data appropriately in the Avatar (EMR) system to generate claims for authorized patient care.
- Communicates all utilization review issues that may compromise patient’s treatment immediately to treatment team including the Executive Director
- Completes all precertification, concurrent review, discharge notifications, retro-authorizations, and appeals when needed. Enters all data in accordance with outlines company workflows.
- Attends treatment team.
- Coordinates with Managed Care and Billing Team to secure single case agreements when indicated for payors with whom RCA is out of network.
- Monitors charts for appropriate documentation to support medical necessity and compliance with payor, company, and regulatory requirements.
- Monitors, works, and responds to all company reports including but not limited to unbilled, chart appeals, and MA pending reports.
- Collaborates with the site Executive Directors to resolve any issues impacting UR activities or preventing ability to obtain authorization. Makes suggestions to improve processes.
- Provide reliable trending analysis of current and past data related to length of stay and days authorized by specific insurance companies.
- Assist with monitoring and improvement of workflows related to collecting self-pay and instituting Medicaid for patients who meet criteria.
- Ensure quality and quantity of documentation in medical records
- This job description is not designed to cover or contain comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.
Education and Experience:
- Bachelor’s degree and 3+ years’ related experience or LPN/RN with related experience
- Excellent verbal and written communication skills.
- Excellent organizational skills with the ability to prioritize workload
- Proficiency in Microsoft Office Suite, including Word, Excel and PowerPoint
Customer Service: Demonstrates concern for meeting internal external customers’ needs in a manner that provides satisfaction for the customer within the resources that can be made available.
Problem Solving: Identifies problems, involves others in seeking solutions, conducts appropriate analysis, searches for best solutions; responds quickly on new challenges.
Communication: Comfortable using a broad range of communication to different audiences in diverse solutions.
Project Management: Coordinates the diverse components of the projects by balancing scope, time, cost, and quality.
Work Environment: May work in a variety of environments including professional offices, clinics, hospitals, or out-patient facilities. They spend much of their time on their feet, actively working with patients.
Physical Demands: While performing the duties of this position, the employee is regularly required to talk or hear. The employee frequently is required to use hands to finger, handle or feel objects, tools or controls. The employee is occasionally required to stand; walk; sit; reach with hands and arms; climb or balance; and stoop, kneel, crouch or crawl. The employee must occasionally lift and/or move objects up to 25 pounds. Specific vision abilities required by this position include close vision, distance vision, color vision, peripheral vision and the ability to adjust focus.
Travel: Travel is primarily local during the business day, although some out-of-the-area and overnight travel may be expected