Utilization Management Specialist-MSH-Case Management-FT-Days

Utilization Management Specialist MSH Case Management FT Days EOW

This position is responsible for coordinating requests for clinical information from third party payers and providing support to a broad client base, both internal and external to the institution. Position responsibilities will include utilization management support functions for patient admissions and continuing stay. This position also facilitates and tracks concurrent adverse determinations and collaborates with Appeals Management Department in managing retrospective denials.

Responsibilities

1. Admission: Payer Authorization & Denials Management. Communicate with payer to obtain request for clinical information, payer authorization and determination (i.e. frequent communication until case determination is established), follows up at regular interval to ensure payer response. Coordinate peer to peers (i.e. If case is denied, ensure timely peer to peer is scheduled)
2. Data Entry & Reporting. Responsible for all relevant communication with payers (time stamped) and entered into electronic tracking system including the following: Process payer denial correspondence mail, end of day reports and fax, enter payer requests, authorization and determination into tracking system, enter required information and tasks into tracking system to alert CM of need for initial and continued stay reviews, and process continued stay and admission denials. Assign denials to the CMs and MD resource as appropriate.
3. Data Entry & Reporting. Oversee collection & integrity of all reported data elements (top-level KPI's; process metrics). Enter all certification and denial data into tracking system based on review of payer communication. Enter in end of day reports, any notification from internal and external case managers and financial screening information.
4. Communication Requirements. Communicates with PFS and ensures relevant info available to PFS for billing purposes. Contact insurance companies and set up peer to peer telephone conference. Communication sent to group providing peer-to-peer contact number, patients insurance ID, and DOB. Responsible for incoming communications via phone or fax and monitors office voice mails. Fax denial letters to centralized MSHS denial department within 48 hours of receipt. Generates and distributes payer Census Logs to external clients. Prioritizes incoming communications and relays messages to Case Managers or other UM staff.
5. Other Tasks as Required. Performs other daily tasks associated with data entry and reconciliation between the electronic tracking systems, the EMR, the finance system and the admitting systems. Maintains office files, equipment and supplies. Performs other duties as assigned.

Qualifications

• Associates degree or equivalent combination of experience (Bachelors preferred).
• 2 or more years of relevant experience.

Required Skills

• Microsoft Office Suite

About Us

Strength through Unity and Inclusion

The Mount Sinai Health System is committed to fostering an environment where everyone can contribute to excellence. We share a common dedication to delivering outstanding patient care. When you join us, you become part of Mount Sinai's unparalleled legacy of achievement, education, and innovation as we work together to transform healthcare. We encourage all team members to actively participate in creating a culture that ensures fair access to opportunities, promotes inclusive practices, and supports the success of every individual.

At Mount Sinai, our leaders are committed to fostering a workplace where all employees feel valued, respected, and empowered to grow. We strive to create an environment where collaboration, fairness, and continuous learning drive positive change, improving the well-being of our staff, patients, and organization. Our leaders are expected to challenge outdated practices, promote a culture of respect, and work toward meaningful improvements that enhance patient care and workplace experiences. We are dedicated to building a supportive and welcoming environment where everyone has the opportunity to thrive and advance professionally. Explore this opportunity and be part of the next chapter in our history.

About the Mount Sinai Health System:

Mount Sinai Health System is one of the largest academic medical systems in the New York metro area, with more than 48,000 employees working across eight hospitals, more than 400 outpatient practices, more than 300 labs, a school of nursing, and a leading school of medicine and graduate education. Mount Sinai advances health for all people, everywhere, by taking on the most complex health care challenges of our time discovering and applying new scientific learning and knowledge; developing safer, more effective treatments; educating the next generation of medical leaders and innovators; and supporting local communities by delivering high-quality care to all who need it. Through the integration of its hospitals, labs, and schools, Mount Sinai offers comprehensive health care solutions from birth through geriatrics, leveraging innovative approaches such as artificial intelligence and informatics while keeping patients' medical and emotional needs at the center of all treatment. The Health System includes more than 9,000 primary and specialty care physicians; 13 joint-venture outpatient surgery centers throughout the five boroughs of New York City, Westchester, Long Island, and Florida; and more than 30 affiliated community health centers. We are consistently ranked by U.S. News & World Report's Best Hospitals, receiving high "Honor Roll" status, and are highly ranked: No. 1 in Geriatrics, top 5 in Cardiology/Heart Surgery, and top 20 in Diabetes/Endocrinology, Gastroenterology/GI Surgery, Neurology/Neurosurgery, Orthopedics, Pulmonology/Lung Surgery, Rehabilitation, and Urology. New York Eye and Ear Infirmary of Mount Sinai is ranked No. 12 in Ophthalmology. U.S. News & World Report's "Best Children's Hospitals" ranks Mount Sinai Kravis Children's Hospital among the country's best in several pediatric specialties. The Icahn School of Medicine at Mount Sinai is ranked No. 11 nationwide in National Institutes of Health funding and in the 99th percentile in research dollars per investigator according to the Association of American Medical Colleges. Newsweek's "The World's Best Smart Hospitals" ranks The Mount Sinai Hospital as No. 1 in New York and in the top five globally, and Mount Sinai Morningside in the top 20 globally.

Equal Opportunity Employer

The Mount Sinai Health System is an equal opportunity employer, complying with all applicable federal civil rights laws. We do not discriminate, exclude, or treat individuals differently based on race, color, national origin, age, religion, disability, sex, sexual orientation, gender, veteran status, or any other characteristic protected by law. We are deeply committed to fostering an environment where all faculty, staff, students, trainees, patients, visitors, and the communities we serve feel respected and supported. Our goal is to create a healthcare and learning institution that actively works to remove barriers, address challenges, and promote fairness in all aspects of our organization.

Job Info

• Job Identification 3039644
• Job Category Administrative
• Job Schedule Full time
• Job Shift Day
• Locations 19 E 98th St, New York, NY, 10029, US

• 19 E 98th St, New York, NY, 10029, US