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Utilization Review Crd-Pre Adm - Lung Transplant

Description

Are you an experienced nurse with a background in managed care or utilization review? Are you looking to make a difference in the care of transplant patients? We are looking for you!

UPMC Presbyterian is hiring a full-time Utilization Review Coordinator to help support our Outpatient Lung Transplant Division, located in Oakland.  In this position, you will provide essential support to the Cardiothoracic Transplant Team by managing communication between patients, staff, providers, schedulers, and all UPMC departments involved in patient care. You will receive and process clinical information pertinent to the facilitation of prior authorizations for medications, procedures, and clinic visits. You will facilitate the comprehensive continuity of care of the cardiothoracic transplant patients

This position will work a regular Monday through Friday daylight schedule. Hours will be from 7:30 am-4:00 pm. No weekends or on-call responsibilities.  

Purpose:
Is responsible for obtaining treatment plans and diagnoses to secure third-party authorization for hospital admissions, tests, treatments, and procedures for transplant patients. Ensures compliance with all HIPPA and appropriate regulatory guidelines.

Responsibilities:

  • Acts as a resource and provides support to coordinator staff in obtaining authorizations to facilitate patient care.
  • Serves on departmental or interdisciplinary committees as requested.
  • Maintains medical records in accordance with hospital and department policies and standards.
  • Participates in activities that enhance professional development including conferences and continuing education programs.
  • Demonstrates on a consistent basis the behaviors that comprise The Basics of Service Excellence.
  • Conveys treatment plan to third-party payors.
  • Provides verbal and/or written clinical information as required to insurers/regulatory agencies in order to obtain authorizations. Documents all necessary information related to authorizations.
  • Acts as a liaison between physician office and insurance companies to ensure payment for prescribed medications, procedures, treatments, and hospital admissions.
  • Acts as a resource to staff regarding third-party payor regulations and processes as they relate to coverage and reimbursement.
  • Collects initial referral information via telephone, fax, or e-mail and distributes information to the appropriate team members in a timely and efficient manner.
  • Coordinates and manages medical management of the cardiothoracic transplant patient including but not limited to patient communications, outside physician offices, electronic medical record management, scheduling all required appointments and testing, obtaining authorizations for medicaionts, procedures and appointments, clerical support, and data entry.
  • Demonstrate the ability to establish priorities, perform assignments and meet productivity thresholds in the allotted time frames while maintaining accuracy and attention to detail.
  • General data entry responsibilities to include:  Collection and verification of demographics and insurance information, test results, and other pertinent information into EPIC databases.
  • Maintain patient confidentiality and prepare, organize and maintain confidential patient charts and clinical records.
  • Maintain weekly/month productivity. 
  • Support Transplant Coordinators and members of the Cardiothoracic Transplant Team.

 

Qualifications

  • Diploma or Associates Degree in Nursing
  • Demonstrated competence in professional nursing practice
  • 2 years of recent clinical experience
  • Ability to obtain and interpret information in terms of specific needs for the authorization process
  • Understanding of a range of treatments needed by transplant patient population
  • Familiarity with various third-party payors and implications of managed care
  • Pre-authorization/utilization review experience desirable
  • Transplantation experience desirable
  • Excellent communication skillsHigh level of organizational skill and ability to manage multiple tasks concurrently

Licensure, Certifications, and Clearances:

  • Registered Nurse (RN)
  • Act 34

UPMC is an Equal Opportunity Employer/Disability/Veteran

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   Current UPMC employees must apply in HR Direct