Utilization Review Technician III

About the Role

Prime Healthcare is an award-winning health system headquartered in Ontario, California. Prime Healthcare operates 54 hospitals and has more than 360 outpatient locations in 15 states, providing over 3.0 million patient visits annually. It is one of the nation’s leading health systems with over 60,000 employees and physicians. Twenty-one of the Prime Healthcare hospitals are members of the Prime Healthcare Foundation, a 501(c)(3) not-for-profit public charity.

Responsibilities

• Coordinate the utilization review and appeals process as part of denial management initiatives.
• Serve as a liaison and coordinate with other UR techs in the team.
• Handle coordination of phone calls, data entry, mailing/faxing appeals, and tracking data from various insurance providers and health plans regarding authorization, expedited reviews, and appeals.
• Document and track all communication attempts with insurance providers and health plans, and scan all related correspondence to the respective EMR/tracking tool.
• Follow up on all denials while working closely with the Corporate/Facility Utilization Review teams, Business Office, and Case Managers.
• Serve as the primary contact and coordinate work to maintain the integrity of tracking government review audits (RAC, MAC, CERT, ADR, Pre/Post Probes, QIO/Medicaid) and other payer audits as assigned.
• Function as a subject matter expert (SME) to support the UR tech team and remote counterparts with specific processes as applicable.
• Support department needs for Release of Information through faxing and mailing, discharge coordination, or other duties as assigned.

Requirements

• Bachelor’s degree or four years of relevant experience required.
• Microsoft Office proficiency.
• Good communication skills.

Preferred Qualifications

• Completion of a medical terminology course.
• Knowledge of HIPAA regulations.

Benefits

Prime Healthcare offers a comprehensive benefits package that provides employees the flexibility to tailor benefits according to their individual needs. Our Total Rewards package includes, but is not limited to:

• Paid time off.
• 401K retirement plan.
• Medical, dental, and vision coverage.
• Tuition reimbursement.
• Many more voluntary benefit options.

Pay

A reasonable compensation estimate for this role, which includes estimated wages, benefits, and other forms of compensation, is $24.65 to $30.03 per hour. The exact starting compensation will be determined at the time of selecting an applicant for hire, considering factors such as skillset, years of applicable experience, education, credentials, and licensure.

Schedule

• Full Time
• Day Shift