UTILIZATION REVIEW SPECIALIST

FLSA Status Non-Exempt Job Role Summary The Utilization Review Specialist interacts with customers in a caring and respectful manner in accordance with Eskenazi Health Core Values. The Specialist acts as a patient information liaison and interfaces with Transitional Support staff, providers and specialists to assist in problem‑solving. Essential Functions and Responsibilities Proactively contribute to Eskenazi Health’s mission: Advocate, Care, Teach and Serve with special emphasis on the vulnerable population of Marion County. Model Eskenazi’s values of Professionalism, Respect, Innovation, Development and Excellence. Interact with all internal and external customers in a caring and respectful manner in accordance with Eskenazi Health Core Values. Perform pre‑certification activities related to inpatient services in accordance with predetermined departmental criteria. Interface with Pharmacy and Specialty Clinic staff to initiate authorization of biological and neoadjuvant medications. Maintain timeliness of payor communication regarding notification of admission, appeals, and retro‑authorizations. Determine validity of coverage following established authorization requirements and refer to the inpatient discharge planner and inpatient Financial Counseling teams for further determinations of coverage, as needed. Communicate and negotiate with payers to obtain approvals for the appropriate care level. Maintain open collaborative active communication with the Utilization Review nurses’ team to ensure timely patient progression through the episode/plan of care. Document and maintain pre‑certification/authorization information accessible by the healthcare system. Maintain denial management processes in collaboration with UR Nurses, physicians, revenue cycle, and business partners. Maintain knowledge of provider manuals and payor practices regarding inpatient authorizations, denial management, and retro‑authorizations. Research and respond to provider inquiries concerning unauthorized claims. Provide direct support to providers regarding utilization review and authorization. Operate within program requirements in accordance with CMS standards. Job Requirements High school diploma or General Equivalency Diploma (GED). 2 years of experience in a healthcare‑related authorization. Experience with Medicaid, Medicare, and Commercial payers. Knowledge of computers and related software. Ability to discern numbers and names, paying specific attention to detail to ensure accuracy in data entry. Works as an effective team member. Knowledge of general office procedures and mandated retention periods for pre‑services. Proficiency in document imaging processes, oral and written communications, customer service, and organization. Knowledge, Skills & Abilities Self‑starter with strong analytical and organizational skills, ability to work independently and under minimal direction/supervision. Demonstrates professional telephone etiquette, strong written and verbal communication skills, and ability to work collaboratively with others (both intra‑ and inter‑departmentally). Ability to perform clerical functions in a health care setting. Proficiency in basic and intermediate word processing (MS Word and Office). Proficiency in spreadsheet applications, reporting skills, managing processes, supply management, inventory control. Ability to determine member benefit coverage via Indiana Medicaid Portal, Atrezzo, Availity, UHC Link, Cohere, Optum, VA, and other payor platforms. Ability to provide direct support to providers regarding utilization, authorization, and referral activities. Knowledge of office procedures and Utilization Management Policies. Team player, verbal and written communication skills, ability to collaborate with the interdisciplinary medical staff, excellent telephone and reception skills, and ability to work flexible hours. Ability to use age‑appropriate communication skills. Knowledge of Hospital policies and procedures, general office procedures, correct English grammar/punctuation/spelling and aptitude for basic mathematical functions. Responsible for maintaining knowledge of provider manuals and payor practices regarding authorizations, denial management, and retro‑authorizations. Demonstrates a general understanding and use of Medical and Insurance terminology. Ability to prioritize workload/schedules and perform duties without direct supervision. Attention to detail and complete work with high rate of accuracy. Flexibility to changing departmental requirements. Ability to coordinate and organize multiple tasks and projects at once. Functions effectively under pressure of deadlines and work volume. Knowledge of medical terminology preferred. #J-18808-Ljbffr Marion County Public Health Department