This non-clinical administrative staff person will perform steps of the certification process including the acquisition of non-clinical and structured clinical data, review of service requirements, and file maintenance. This individual will perform scripted clinical screening that does not require evaluation or interpretation of clinical information. This position performs activities that allow the first level reviewers to primarily allocate their time to interpreting clinical data, applying review criteria, making certification determinations, and perform discharge planning. The individual is non-licensed and therefore is only responsible for making non-clinical administrative judgments. The individual is under the supervision of a licensed registered nurse, and all calls requiring clinical assessment are forwarded to the RN for review.

JOB DUTIES:

1. Makes outgoing calls to hospitals to determine if patients are still in-house, request discharge dates, disposition and retro, initial or concurrent clinical reviews. The individual will not be responsible for taking clinical reviews directly from hospital reviewers or nurses. Instead, requesting for call back with clinical or transferring the call to a first level reviewer.
2. Send faxes to hospitals with request for clinical reviews and/or discharge needs may also be necessary.
3. Monitors and attaches faxes on the fax server as assigned.
4. Transfers all messages and clinical reviews from voice mails into the UR system. All simple messages may be deleted from the voice mail, but all clinical review messages must be left on voice mail so UR nurse can review and supervise the clinical data entered into the UR system by the individual. Once the assistant is proven adept at clinical data transfer, permission will be granted to remove voice mail messages once entered.
5. Performs any scripted clinical screening as assigned following the Policy and Procedure for Scripted Clinical Screening that does not require evaluation or interpretation of clinical information. In the event that the request requires interpretation, the request will be forwarded to a first level reviewer.
6. Verifies that a provider is in the network or identifies potential PPO providers, and clarifies incomplete or contradictory non-clinical data.
7. Notifies providers of certification and reads the disclaimer, produces and sends to print batch certification letters after completion of scripted screenings
8. Communicates with MD offices, hospital medical records or UR departments, case managers and customers as needed.
9. Documents all activities in the UR file according to procedure
10. Assist intake administrative staff as staffing necessitates
11. Other duties as assigned.

PM21

EDUCATION: High School Diploma or equivalent with some post-secondary education desirable. Courses in medical terminology preferred.

SKILLS: Knowledge of computers along with fluent keyboarding, data entry in databases, word processing, and multiple line telephone systems. Bi-lingual helpful but not required.

EXPERIENCE: Experience in the health care industry such as medical transcription. Successful completion of the URA orientation program and maintenance of minimal QA standards. 1-2 years experience or relevant education in the health care industry

PERSONAL QUALIFICATIONS: Helpful and friendly telephone personality. Ability to proof written material accurately, accurate data entry ability. Ability to organize a large variety of tasks and prioritize as directed by UR Manager. Ability to work with a variety of professional staff and provide clerical backup as needed for that staff. Understanding of customer service.

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