RN UTILIZATION MANAGEMENT SPECIALIST

Overview 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, applying approved clinical appropriateness criteria, InterQual™ Acute Care Criteria, to monitor appropriateness of admission and continued stays and documents findings based on Department standards. Responsibilities include 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 obtain payer approval for efficient utilization of resources and appropriate reimbursement of care and services. Maintains current organized databases regarding payer requirements, payer reviews, contacts, decisions and appeals, and reports trends relative to third‑party payer reviews. Responsibilities Demonstrates excellent customer service. Contributes to organization success targets for patient satisfaction by meeting Utilization Management Specialist expectations for Customer Satisfaction. Performs medical necessity reviews on all patients regardless of payor ASAP after admission. Conducts continued stay reviews no less than every 48 hours unless indicated per InterQual™ and/or the patient’s payor source. Verifies and validates 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 follow the EHR referral process guidelines. Reviews all Medicare surgical patients listed outpatient against Medicare inpatient‑only list to determine correct status. Follows EHR referral process guidelines for Medicare re‑admissions questioning the "same episode of care" within 30 days. Follows EHR referral process guidelines when a physician will not approve a status order change. Follows EHR referral process guidelines for Medicare continued stay reviews that no longer meet inpatient criteria. Contributes to organization success targets for net operating margin. Ensures availability of accurate and timely information. Demonstrates age‑specific competency in selected age groups: newborn, infant, pediatric, child, adolescent, adult, and geriatric. Utilizes latest technology to obtain information from multidisciplinary 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 signs, 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. Obtains 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 staff and facilitates meetings with payers; works to maximize positive outcomes. Qualifications RN with current license in State of Michigan. 3 years successful performance in utilization management. Demonstrated clinical competence. Demonstrates competence in denial/appeals management and utilization management. Excellent letter writing and verbal communication skills. Exceptional understanding of disease process and treatment regimens associated with designated patient populations. Maintains current knowledge by attending conferences, seminars and reading journals or research articles. Demonstrates critical thinking skills, analyzing multiple issues impacting outcomes. Excellent problem‑solving skills and ability to manage many situations simultaneously; able to adjust to priorities that may change minute by minute. Strong commitment to collaboration and teamwork; demonstrated ability to work as a member of a team where assignments must be coordinated with peers. Good computer skills. Excellent communication skills, negotiation skills, diplomacy and assertiveness. Solid understanding of healthcare industry, technology and regulations. Professional approach to work, including strong sense of responsibility for assigned duties. Working Conditions / Physical Demands Ability to maintain punctual attendance consistent with ADA, FMLA, and other federal, state, and local standards. Frequent standing, walking, sitting, talking, hearing. Occasional lift up to 100 or more lbs.; carrying, pushing, climbing, balancing, stooping. Occasional kneeling, crouching, squatting, crawling, twisting. Occasional reaching, handling, feeling, near vision; midrange vision, far vision, depth perception. Occasional visual accommodation, color vision, field of vision. #J-18808-Ljbffr