RN UTILIZATION MANAGEMENT SPECIALIST

Utilization Management Specialist

The Utilization Management Specialist demonstrates excellent customer service performance in that his/her attitude and actions are at all times consistent with the standards contained in the Vision, Mission and Values of Covenant HealthCare and the commitment to Extraordinary Care for Every Generation. The Utilization Management Specialist provides support for the Clinical Resource Management Department by serving as a liaison with external agencies and third party payers. The Utilization Management Specialist will apply approved clinical appropriateness criteria, InterQual™ Acute Care Criteria, to monitor appropriateness of admission and continued stays and documents findings based on Department standards. Responsibilities includes collaborating with Case Management Specialist, physicians, payers, Patient Accounting, Health Information Management, Admitting, and other members of the health care team, and communicating with external parties to achieve desired outcomes for obtaining payer approval for efficient utilization of resources, and appropriate reimbursement of care and services. This individual maintains current organized databases regarding payer requirements, payer reviews, contacts, decisions and appeals, and reports trends relative to third party payer reviews.

Demonstrates excellent customer service.

Contributes to organization success targets for patient satisfaction by meeting the Utilization Management Specialist expectations for Customer Satisfaction.

Medical necessity reviews will be accomplished on all patients regardless of payor as soon as possible after admission.

Continued stay review will be accomplished no less then every 48 hours thereafter unless indicated per InterQual™ and/or the patient's payor source.

Verify and validate that the Physician order is compatible with InterQual™and the patient class in Epic (3 point match).

All Medicare medical inpatient and observation patients that do not meet inpatient criteria will follow the EHR referral process guidelines.

Reviews all Medicare surgical patients that are listed outpatient against the Medicare Inpatient only list to determine correct status.

When the procedure is normally done as outpatient but something occurs intraoperatively to cause it to become an inpatient admission, will follow the EHR referral process guidelines.

Medicare re-admissions if questioning the "same episode of care" within 30 days, will follow the EHR referral process guidelines.

When a physician will not approve a status order change, will follow the EHR referral process guidelines.

Medicare continued stay reviews that no longer meet inpatient criteria, will follow the EHR referral process guidelines.

Contributes to organization success targets for net operating margin.

Ensures the availability of accurate and timely information.

Demonstrates age specific competency in the selected age groups: newborn, infant, pediatric, child, adolescent, adult, and geriatric.

Utilizes latest technology to obtain information from multi-disciplinary areas to obtain authorization of days for a patient's stay in the hospital.

Facilitates delivery of clinical information, i.e. electronic transfer.

Assures that patient's level of care is reflected by the sign's, symptoms, and treatment delivered for inpatient, Ambulatory, Obstetrics monitor, and Observation stays.

Negotiates with payers to facilitate reimbursement.

Assists with governmental agency requests for information and prepares / provides reports.

Works collaboratively with Patient Accounting, Patient Admission and Registration, HIM, and Finance Department to optimize reimbursement.

Obtain payor authorization for reimbursement on Urgent and Emergent hospital admissions.

Utilizes information provided by Case Management Specialist and identifies additional information to communicate to review agencies about patient's condition and severity of illness, treatments and intensity of service, and plan of care.

Documents and manages third party payer contacts and certification information.

Maintains an organized database of payor requirements and contracts.

Prepares, issues, distributes, and tracks notices of non-coverage.

Becomes internal expert for Case Management Specialist and others on reimbursement requirements and strategies for success.

Reviews utilization management ramifications of third party payer contracts and maintains current knowledge of contract requirements.

Works with the healthcare team to demonstrate fiscal responsibility by being conscious of the need to appropriately use the resource dollars available.

Maintains flexibility to changes in delivery of clinical information, i.e. electronic transfer.

Completes payor pre-notification / pre-certification to obtain approval authorization for scheduled surgical patients when required.

Coordinates contact between physician and payors.

Manages and responds to concurrent third party payer denials of outpatient and inpatient cases alleged to be medically inappropriate, e.g.days of care, services, entire stays, etc.

Manages and responds to Medicaid denials of inpatient cases retroactively on readmission and transfer cases requiring PACE authorizations.

Serves as a resource to the health care team related to denial management and utilization management.

Demonstrates excellent communication skills, negotiation skills, diplomacy and assertiveness.

Builds and nurtures professional, effective relationships with all members of the Healthcare team.

Manages conflict effectively, striving for win-win outcomes.

Serves as a liaison that interacts with physician office staffs and facilitates meetings with payers. Works to maximize positive outcomes.

EDUCATION/EXPERIENCE

RN with current license in State of Michigan required.

3 years successful performance in utilization management (Preferred).

KNOWLEDGE/SKILLS/ABILITIES

Demonstrated clinical competence.

Demonstrates competence in denial/appeals management and utilization management.

Excellent letter writing and verbal communication skills required.

Has exceptional understanding of the disease process and treatment regimens associated with designated patient populations.

Maintains current knowledge by attending conferences, seminars and reads journal or research articles.

Demonstrates critical thinking skills, analyzing multiple issues impacting outcomes.

Excellent problem solving skills and the ability to manage many situation simultaneously. Able to adjust to priorities that may change minute by minute.

Strong commitment to collaboration and teamwork, with demonstrated ability to work as a member of a team where assignments must be coordinated with peers.

Demonstrates good computer skills.

Demonstrates excellent communication skills, negotiation skills, diplomacy and assertiveness.

Has a solid understanding of the Healthcare industry, technology and regulations.

A professional approach to work, including a strong sense of responsibility for assigned duties.

WORKING CONDITIONS/PHYSICAL DEMANDS

Ability to maintain punctual attendance consistent with the ADA, FMLA, and other federal, state, and local standards.

Frequent standing, walking, sitting, talking, hearing.

Occasional lift up to 100 or more lbs.

Occasional carrying, pushing, climbing, balancing, stooping.

Occasional kneeling, crouching, squatting, crawling, twisting.

Occasional reaching, handling, feeling, near vision.

Occasional midrange vision, far vision, depth perception.

Occasional visual accommodation, color vision, field of vision.