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Utilization Review Business Support Specialist

Allegheny Health Network

  • Company AHN
  • Home, PA
  • Administrative Services
  • Full time
  • Day (United States of America)

Company :

Allegheny Health Network

Job Description : 


This position is responsible for covering vast roles within the Utilization Review management team that include managing bill processing, downgrades, entry into the system including reg, insurance verification, authorization, and financial counseling/management, and working in tandem with RN to ensure all patients coming into the health system through transfers/direct admissions/ED have appropriate documentation ensuring expediting of claim and authorization for RN when insurance companies accept clinical review.


  • Ensures accurate and complete documentation and information on all transfers and admissions into AHN for appropriate order writing and level of care upon entry into the system (with RN support). (45%)
  • Implements and organizes downgrades compliantly and per documentation. (10%)
  • Investigates concerns for improper billing/coding practices and recommends corrective action, works collaboratively to understand denial/appeal management process and alert edits/rejections. (10%)
  • Identifies trends with claim holds and denials and provides communication to all necessary parties. (10%)
  • Communicates with all parties in a professional manner to alert of specific problem issues. (10%)
  • Ensures confidentiality of all patient accounts by following HIPAA guidelines. (5%)
  • Proficient with department software, analytical tools, basic coding and billing knowledge, and revenue cycle operational policies. (5%)
  • Performs other duties as assigned or required. (5%)



  • Bachelor's degree in health care related field or three years' experience in healthcare environment or related field with exposure to healthcare coding, billing, reimbursement, registration, insurance verification


  • 1 year experience with medical necessity appeals
  • Competency of inpatient and outpatient coding guidelines

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement : This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times.  In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. 

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Pay Range Minimum:


Pay Range Maximum:


Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations.  The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability. 

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Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled/Sexual Orientation/Gender Identity ( )

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