Utilization Reviewer - System Care Management - Full Time

Sayre, PA, United States
Apr 12, 2019


Job Description

Guthrie Entity

Robert Packer Hospital



40 hours/week

Pay Grade



CPR / AED Certification
Licensed Practical Nurse

FLSA Status


Main Function

The Utilization Management (UM) Reviewer, in collaboration with Care Coordination, Guthrie Clinic offices, other physician offices, and the Robert Packer Hospital Business Office, is responsible for the coordination of Utilization Management (UM) processes and requirements of prior authorization/certification for reimbursement of patient care services.  The responsibilities include:• Facilitating communication between physician offices, payers, Care Coordination and  other hospital departments as appropriate to obtain prior authorization required to meet contractual reimbursement requirements and to assist in ensuring generation of clean claims in a timely manner• Securing authorization as appropriate• Documenting payer authorization• Screening the appropriateness of level of care/service• Facilitating issue resolution with payer sources in collaboration with other hospital departments or clinic offices as appropriate• Demonstrating ongoing competence in payer requirements, as defined collaboratively with Patient Business Services and Care CoordinationAdditionally, the position works closely with the Care Coordination department to support data collection and aggregation associated with UM processes and operations.


Current LPN licensure or eligibility for licensure required.  Relevant experience in health care may be considered in lieu of educational requirement


Minimum of five years clinical experience in an acute health care setting.  Must possess strong communication and organizational skills, be able to work independently and to complete work within specified time frames.  Knowledge of health benefit plans and related UM requirements preferred.  Experience with CPT4/ICD-9 coding, medical record or chart auditing, and experience in utilization management processes preferred.  Knowledge of computer applications (such as Microsoft word processing and spreadsheets) desirable. 

How To Apply

Guthrie is an equal opportunity employer. To apply for a position at Guthrie please visit www.guthrie.org/careers


Job Info

Apr 12, 2019


United States