Job Title - Utilization Review Specialist
Reports Into General Manager - Operations
Direct Reports Supervisors / Assistant Managers
OUR COMPANY AGS Health is more than a revenue cycle management company-we're a strategic partner for growth.
With expert services complemented by AI-enabled technologies and high-touch support, AGS Health is
the premier revenue cycle partner for leading health systems, physician groups, and academic medical
centers in the U.S. With expert insight into modern revenue cycle practices, the company pairs cuttingedge technology with college-educated, trained RCM experts to help clients optimize workflows,
maintain compliance, prevent revenue leakage, and achieve a high-performance revenue cycle. AGS
Health employs more than 12,000 team members globally and partners with more than 100 clients
across a variety of care settings, specialties, and billing systems. RESPONSIBILITIES
? Provide health care utilization review services regarding admissions, observations, Discharge
Wqs based on the payer types and review types.
? Review admissions and service requests within assigned unit for prospective, concurrent, and
retrospective medical necessity and/or compliance with reimbursement policy criteria.
? Assist with issues related to coding, medical records/documentation, precertification,
reimbursement and claim denials/appeals.
? Notifies attending physician and other members of the health care team of inappropriate
admissions, denials, end of authorized days, or other factors that have a reimbursement
impact.
? Consults with attending physician when documentation in the medical record does not support
admission or continued stay and seeks to ensure completeness of all clinical documentation.
? Functions as liaison between the Physician Advisor and the attending physician..
? Documents denial information in electronic medical record system including attempts at
resolution/overturning of the denial.
? Provides all payor communication to be scanned into the system for use in appeals.
? Application of MCG and InterQual guidelines for each case review to determine the status.
? Consults with medical and treatment staff regarding client diagnosis, medical justification,
length of treatment, and case documentation.
? Participates in utilization and peer review meetings and projects. COMPETENCIES, SKILLS AND OTHER REQUISITES
? Excellent written and spoken English
? Unflinching integrity and personal work ethics
? Self-starter who strives forself and team excellence
? Flair for client satisfaction
? Attention to detail and concern for accuracy
? Excellent time management skills and multi-tasking ability
? Excellent team player
? Compliant to rules and regulations
ACADEMIC AND PROFESSIONAL BACKGROUND
? Academic qualification for this role is a graduate in Nursing.
? Required Certifications/Licensure Registered Nurse currently licensed COMPLIANCE
? Awareness and implementation of ISO, ISMS and GRIC policies
? Adherence to the rules and regulations as outlined by the management. COMPENSATION AND BENEFITS Competitive remuneration + annual performance-based
bonus +standard industry benefits. Relocation package, per company policy will apply for candidates
outside the office base city. ASSESSMENT / INTERVIEW PROCESS
1. Personal Interview (HR)
2. Domain Panel Interview
3. HR Discussion
