Utilization Management Specialist
3 weeks ago
The Utilization Management Specialist coordinates communication with admitting financial counselors, case management, patient financial services, and payers to ensure all inpatient services provided by the hospital are authorized by appropriate payer. The Utilization Management Specialist works with case managers to facilitate timely transmission of concurrent and discharge reviews to the appropriate payer to ensure all days are authorized and documented. Clinical reviews and continued stay authorizations will be documented in the appropriate electronic system by the Utilization Management Specialist.
**Essential Duties**:
- Collaborates with financial counselors to ensure all insurance contacts are identified and documented in eCare.
- Performs admission and concurrent InterQual reviews as needed to document medical necessity.
- Collaborates with case managers to ensure timely completion of clinical reviews.
- Responds timely to payer requests for clinical reviews and completes verbal reviews as needed.
- Elevates issues regarding timely reviews and authorizations to manager/director.
- Communicates with payers when patient status changes from observation/extended recovery to inpatient to obtain authorization for inpatient stay.
- Initiates a call to payers to confirm receipt of clinical reviews and authorization of all days upon discharge.
- Coordinates retrospective clinical reviews as requested by payers.
- Documents communication with payers and outcomes of discussions in ecare and FUSS notes.
- Inputs authorization data into spreadsheets to generate reports for analysis.
- Provides phone coverage for the department in the absence of the administrative assistant.
- Assists with denial management to identify opportunities to improve department processes.
- Represents the department in a positive and professional manner.
- Demonstratives collaborative working relationships with case managers and payers to ensure authorizations are obtained and current.
- Maintains awareness of payer/reimbursement practices and requirements.
- Assists with orientation of new personnel regarding payer communications.
- Identifies opportunities to improve department workflow and process regarding payer communication.
- Other duties as assigned by Manager or Director.
**Required Qualifications**:
- Req High school or equivalent
- Req Specialized/technical training Licensed Vocational Nurse graduate from an accredited school.
- Req Experience with computer data entry and spreadsheets
- Req Good verbal and written communication skills.
- Req Medical terminology knowledge.
- Req Ability to be self directed and work with mínimal supervision.
- Req Ability to work collaboratively with multiple personnel and prioritize multiple tasks.
**Preferred Qualifications**:
- Pref Experience caring for transplant patients
**Required Licenses/Certifications**:
- Req Licensed Vocational Nurse - LVN (CA DCA)
- Req Fire Life Safety Training (LA City) If no card upon hire, one must be obtained within 30 days of hire and maintained by renewal before expiration date. (Required within LA City only)
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