Utilization Management Assistant

Creating Life Better Here starts with you. At San Juan Regional Medical Center, we're more than a healthcare provider—we're a values-driven organization dedicated to delivering exceptional care. As a team member, you help fulfill our mission to make life better here for our community.

The Utilization Management (UM) Assistant is entrusted to provide excellent service and set a positive tone for every customer while serving as the liaison between the Utilization Management Team and payors. This role involves authorizations, compiling denial and appeal documentation, tracking, and monitoring concurrent and retrospective denials, and assisting with peer-to-peer conversations for denial mitigation.

Required Behaviors:

• As you go about fulfilling this mission, your work habits and work relationships should embody SJRMC's values. These values are our culture, our identity as an organization. Sacred Trust, Personal Reverence, Thoughtful Anticipation, Team Accountability and Creative Vitality ask more of us than merely completing some list of tasks. Our values ask for a deeper level of commitment, and what is asked of us we freely give because we believe in our mission.

Required Qualifications:

• High School diploma or equivalent
• Five (5) years’ experience in healthcare and or insurance
• Strong communication skills
• Excellent customer service skills and phone etiquette
• Ability to function autonomously
• Experienced in computer programs including Excel and Office
• Ability to set and maintain priorities when dealing with multiple demands and interruptions.
• Knowledge of insurance and billing requirements

Preferred Qualifications:

• Medical Terminology
• Utilization Management experience

Duties and Responsibilities:

• Receives clinical denials through phone calls, fax and EMR
• Documents inpatient authorizations and payor communication
• Provides initial and concurrent clinicals to payors through EMR and payor portals
• Maintains denial and appeal work ques for the UM team
• Reviews and compiles denial and appeal documentation and submits in a timely manner
• Tracking and monitoring concurrent and retrospective denials
• Assists with coordination of peer-to-peer conversations for denial mitigation
• Coordinates W2 meetings and completes provider correspondence
• Exhibits effective communication
• Performs related duties and responsibilities as required.
• All SJRMC Employees are responsible for implementing SJRMC’s Service Standards into their activities: Safety, Courtesy, Effectiveness, and Stewardship
• Other duties as assigned

Physical Demands and Environmental Work Conditions:

• Prolonged sitting/standing/walking
• Fast paced environment
• High level of activity
• Possible exposure to communicable disease
• Repetitive motion (i.e., keyboard usage)

Sensory Requirements:

• Must be able to see with corrective eyewear
• Must be able to hear clearly with assistance