Utilization Analyst

Job Summary

Coordinates and supervises data management, analyses and reporting for KFH utilization management and Continuing Care Services, SCPMG, KFHP Outside Services management (i.e., day utilization at Outside facilities, and the Emergency Prospective Review Program and Air & Ground Transportation Program, using (implementing and refining) computerized data management systems and in manually maintained utilization data.

Essential Responsibilities

• Coordinates and supervises data and reporting needs, data collection process and data processing issues and provides timely utilization data and analytic support.
• Frequent contacts with other organizational units and outside facilities staff to obtain, verify and/or provide information, e.g., works with Regional Claims and outside hospitals to reconcile billing charges.
• Answers inquiries and educate patients, physicians and hospitals on covered benefits and charges.
• Provides information and assistance to Health Plan members during claims review process and coordinates authorized and non-authorized claims review.
• Documents outside medical services and reinforce procedures for patients seen in outside emergency department.
• May coordinate and supervise Air & Ground Transportation and Prospective Review Authorization Program.
• Coordinates and supervises claims and referral information.
• Provides information regarding member admissions to outside facilities.
• Maintain the consistency and integrity of the non-KFH utilization bed track computerized data management system.
• May assist in scheduling patient appointments and coordinating patient care.