GENERAL SUMMARY: Responsible for supporting the Utilization Management team by obtaining documentation/signatures needed for insurance purposes and the ability to explain the required documents to patients in our care. Using knowledge of insurance criteria and guidelines to ensure that the appropriate insurance(s) have been loaded for each patient. Monitors, assists with, and notates utilization activities including but not limited to denials, authorizations, appeals and retro authorizations for patients under the direction of Utilization Management. Responsible for ensuring coding and authorization reviews are completed, and we have an appropriate authorization on file for the procedure being ordered. Ensures documentation is provided for insurance company requests and/or determinations. Collaborates in an interdisciplinary manner to optimize patient care, quality reimbursement, and regulatory compliance. PRINCIPAL JOB FUNCTIONS:
Commits to the mission, vision, beliefs and consistently demonstrates our core values.
Understands and operationalizes federal regulations regarding Advance Directives, COBRA, Medicare, Corporate Compliance, Joint Commission, OSHA and HIPAA; reports safety and customer concerns.
Adheres to current rules, regulations and policies related to the Medicare program, Medicaid program and commercial payer guidelines.
Verifies eligibility and coverage on all new incoming inpatients.
Reviews and indexes insurance responses/correspondence while alerting the appropriate personnel.
Answers UR department phone and routes calls to appropriate personnel as needed.
Administers and documents appropriate Medicare Outpatient Observation Notice (MOON), Important Message from Medicare (IMM), Hospital Issued Notices of Non-Coverage (HINN), Advanced Beneficiary Notices (ABN) and other documents as deemed appropriate.
Assists with admission notification for commercial payers.
Submits detailed, customized appeals to payers based on review of medical records and in accordance with Medicare, Medicaid, and third-party payer guidelines as well as Bryan Health policies and procedures.
Monitors inpatient authorization statuses and notates patient accounts appropriately.
Coordinates with assigned representatives of insurance companies to come to a resolution on difficult inpatient authorizations and/or claim denials.
Communicates with Utilization Review Nurses, providers/clinic teams and third-party vendors to assist in the scheduling of Peer to Peer reviews to overturn inpatient denials.
Tracks and trends denials to provide statistical feedback to members of Utilization Review Committee and the Medical Director in order to put policies in place to avoid future denials.
Acts as an communication liaison between Utilization Review, Registration, Coding, prior authorization, hospitalists and mid-levels, and billing.
Acts as a communication liaison between Utilization Review, Registration, Coding, Prior Authorizations, Clinic teams, and Billing.
Assists the Utilization Review Nurses and serves as a resource regarding inpatient insurance guidelines and requirements.
Assists Utilization Review Nurses with inpatient authorizations by compiling and submitting all appropriate forms and clinical documentation necessary to gain and maintain approval.
Audits the surgery schedule daily to ensure that an appropriate order was received and the an authorization was obtained.
EDUCATION AND EXPERIENCE: Bachelor's degree in business or health sciences preferred. Certified Medical Coder (CPC) or Certified Professional Biller (CPB) certification preferred. Minimum of one (1) year of experience in Medical Billing/Patient Accounts required. PHYSICAL REQUIREMENTS: (DOT) - Characterized as sedentary work requiring exertion up to 10 pounds of force occasionally and/or a negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects, including the human body. |
Bryan Health
Oct 09, 2026