Utilization Management Specialist

1 week ago

Baltimore, United States MedStar Health Full time
General Summary of Position

Job Summary:

MedStar Health is looking for a Utilization Management Specialist to join our team We are looking for someone with knowledge of databases and business software applications, as well as critical thinking and problem-solving skills.

The Utilization Management Specialist will support the concurrent and retrospective utilization management process by collaborating with payors, MedStar Financial Services, and Case Management staff to assure certification and payment of acute care days. Participates in the analysis of denial outcomes data that includes the financial, utilization, performance, and quality improvement activities. Assists in developing new databases for capturing denial and utilization review management.

Join one of the largest healthcare systems in the Baltimore-Washington metro region, also recognized as one of the "Healthiest Maryland Businesses". Apply today and learn how MedStar Health can be your next great career move

Primary Duties:

  • Analyzes and interprets data to provide consistent, meaningful information for the Denials Management Team and specific service lines as indicated. Presents data in a comprehensive format to facilitate understanding and support the decision-making process. Synthesizes and translates data into useful information that can assist service lines enhance their performance.
  • Collaborates with Finance, PFS (Patient Financial Services), Operations, and hospital service lines to develop and facilitate the electronic gathering of appropriate denial/appeal and performance measurement data. Supports development and generation of performance reports.
  • Develops, maintains, and updates databases to assist the Clinical Review Nurses in the Case Management department with data capturing, monitoring, and reporting activities stemming from their medical record reviews. Maintains confidentiality of all interdepartmental correspondence. Effectively communicates clinical information and negotiates with payors to obtain authorization for appropriate level of care and length of stay. Documents interactions/ interventions.
  • Maintains Care Management and performance improvement databases. Monitors consistency, validity, and reliability of data. Maintains, updates, and runs reports from current databases used to collect denial and utilization management data. Generates routine and ad hoc data on resource utilization and outcome measures from information databases. Measures change and trends. Prepares trended reports/presentation for denials management team (Appeals Coordinator).
  • Proactively identifies any concerns (e.g., denials, certification status) or change in payor information to Case Manager to concurrently obtain certification of acute days. Streamlines data management processes while gathering utilization management information. Tracks specific denial information for specific departments: Case Management (denied days, utilization review) and other departments/services as needed. Supports performance improvement teams to improve processes by generating performance improvement outcome analysis.
Qualifications:
  • High School Diploma or GED.
  • Knowledge of third-party reimbursement and medical terminology.
  • 2 years related experience; 1 year experience in case management or utilization review.
  • Associate degree in business or healthcare field preferred.
Why MedStar Health?
At MedStar Health, we understand that our ability to treat others well begins with how we treat each other. We work hard to foster an inclusive and positive environment where our associates feel valued, connected, and empowered. We live up to this promise through:
  • Strong emphasis on teamwork - our associates feel connected to each other and our mission as an organization. In return, our effective team environment generates positive patient outcomes and high associate satisfaction ratings that exceed the national benchmark.
  • Strategic focus on equity, inclusion, & diversity - we are committed to equity for all people and communities.We continue to build a diverse and inclusive workplace where people feel a sense of belonging and the ability to contribute to equitable care delivery and improved community health outcomes at all levels of the organization.
  • Comprehensive total rewards package - including competitive pay, generous paid time off, great health and wellness benefits, retirement savings, education assistance, and so much more.
  • More career opportunities closer to home - as the largest healthcare provider in the Baltimore-Washington, D.C. region, there are countless opportunities to grow your career and fulfill your aspirations.

About MedStar Health
MedStar Health is dedicated to providing the highest quality care for people in Maryland and the Washington, D.C., region, while advancing the practice of medicine through education, innovation, and research. Our team of 32,000 includes physicians, nurses, residents, fellows, and many other clinical and non-clinical associates working in a variety of settings across our health system, including 10 hospitals and more than 300 community-based locations, the largest home health provider in the region, and highly respected institutes dedicated to research and innovation. As the medical education and clinical partner of Georgetown University for more than 20 years, MedStar Health is dedicated not only to teaching the next generation of doctors, but also to the continuing education, professional development, and personal fulfillment of our whole team. Together, we use the best of our minds and the best of our hearts to serve our patients, those who care for them, and our communities. It's how we treat people.

MedStar Health is an Equal Opportunity (EO) Employer and assures equal opportunity for all applicants and employees. We hire people to work in different locations, and we comply with the federal, state and local laws governing each of those locations. MedStar Health makes all decisions regarding employment, including for example, hiring, transfer, promotion, compensation, benefit eligibility, discipline, and discharge without regard to any protected status, including race, color, creed, religion, national origin, citizenship status, sex, age, disability, veteran status, marital status, sexual orientation, gender identity or expression, political affiliations, or any other characteristic protected by federal, state or local EO laws. If you receive an offer of employment, it is MedStar Health's policy to hire its employees on an at-will basis, which means you or MedStar Health may terminate this relationship at any time, for any reason.

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