COMPANY OVERVIEW

Volunteers of America Chesapeake & Carolinas empowers self-reliance and inspires hope. As a church without walls, we do this through personalized housing, ministry, health, and human services that benefit vulnerable individuals, their families, and the community. Founded in 1896 in Baltimore, MD by social reformers, Ballington and Maud Booth, we were one of the first of over 30 affiliates of Volunteers of America – one of the nation’s largest and most comprehensive human services organizations.

Our founders envisioned a movement dedicated to reaching and uplifting the American people. On behalf of the organization, the Booths pledged “to go wherever we are needed, and do whatever comes to hand”. Their declaration continues to guide Volunteers of America's impact on “Helping America’s most vulnerable.”

Through a dedicated and committed team of more than 850 employees and thousands of volunteers, we provide critical care, support services and hope to thousands of people each year throughout Virginia, Maryland, the District of Columbia and the Carolinas. We firmly believe our employees drive the success of the organization. Through our diversity, equity, and inclusion efforts, we endeavor to attract, engage, and retain qualified, diverse, compassionate individuals to join our journey and experience a work environment that offers challenging, stimulating and financially rewarding opportunities.

The Utilization Specialist will report to the Executive Director of Federal & MCO Revenue Cycle Management and will complete/submit all necessary documents/applications to credential providers with respective insurance carriers and national entities, including CAQH and NPI Registry. They will maintain current utilization processes for all insurance carriers. They will complete routine review of carrier policies and forms to ensure current and update documents are being utilized; frequency determined by insurance or national entity. Finally, provides utilization review and denials management for an assigned patient case load. This role utilizes nationally recognized care guidelines/criteria to assess the patient's need for outpatient. The role requires interfacing with the programs, medical team, other staff, physicians.

RESPONSIBILITIES:

• Enter and maintain system profiles/databases used for sharing provider and authorization numbers.
• Written and/or verbal follow-up of outstanding utilization request with client and/or insurance carriers.
• Research/resolve accounts appearing on the A/R reports related to utilization matters.
• Assist billing team leadership to address denials with all billing teams.
• Identifying current/potential utilization issues specific to outstanding receivable.
• May participate in training/meetings with Payers, internal and external departments.
• Conduct client contact(s) and Management, etc., to address trends in denials or unprocessed claims.
• Conduct utilization training/quality review process and quality assurance of other team members or the provider practice as needed.
• May provide support to billing team in case of staff shortage.
• The position also facilitates and tracks concurrent adverse determinations and collaborates with other disciplines regarding patient care management.
• Generates and distributes Payor Census Logs to external and on-site Program Managers.
• Contacts third party payers to assist in obtaining authorization.
• Responsible for incoming communications via email, mail, phone, or fax; monitors office voice mails.
• Provides patient-specific information to payors as needed.
• Assist in other duties as assigned.

EFFECT ON END RESULT:

• Maintain credentialing status for all providers at 100% and ready for any audit.
• Ensure that all authorizations are valid, renewed prior to the expirations date, and ready for any payor review/audit.
• Assist with increasing revenue by ensuring that all of the above is addressed timely within 24 to 48 hours of discovering an error or misstep.

PHYSICAL REQUIREMENTS:

The physical requirements described below are representative of those that must be met by an employee to successfully perform the essential duties of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform their essential duties.

• The ability to safely operate a motor vehicle to transport oneself, consumers, and program supplies, as necessary.
• The physical ability to travel to assigned locations, stand, stoop, bend, reach, pull, push, lift, grasp, climb, talk, see, hear, and perform basic and light home maintenance activities, and operate office equipment.
• Operating office equipment requiring continuous or repetitive hand/arm movements.
• The ability to remain in a sitting position for extended periods of time

OTHER DUTIES:

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.

REQUIREMENTS

• Bachelor’s degree preferred.
• One to two years of AR follow up and previous Utilization experience with a working knowledge of various insurance. Utilization requirements by provider type and specialty preferred.
• Experience with prior Authorization for ensuring all scheduled sessions are authorized for the correct programs and review any errors and make corrections.
• Experience with understanding that CPT code and that diagnosis is considered payable under the carrier’s regulations and how to confirm and research.
• Working knowledge of commonly used concepts, practices, and procedures within healthcare as it pertains to billing reimbursement management.
• Strong customer service experience and ability to work with and communicate with individuals of varying disciplines including respect for cultural difference.
• Excellent written and oral communication skills required.
• Excellent computer skills in the area of MS Excel, MS Word, MS Outlook, and Adobe.
• Ability to work independently with minimal supervision.
• Strong problem solving and execution skills.
• Bilingual in any language a plus not required.