Utilization Management Specialist (RN or LPN required) - ED
JOB SUMMARY: Facilitates optimal reimbursement through accurate certification and complete chart documentation ensuring that the appropriate admission status is ordered. Conducts initial admission based on utilization review medical necessity criteria. Refers cases for secondary review when appropriate. Refers and consult with the multidisciplinary team to promote appropriate communication in the absence of definitive documentation and/or review criteria to support hospital stay.
Facilitates optimal reimbursement through certification and denial processes.
Facilitates throughput of patients admitted urgently or emergently through the emergency department.
Participates as an active partner with multidisciplinary team members to ensure case is in the appropriate level of care setting.
The responsibilities listed are a general overview of the position and additional duties may be assigned.
UTILIZATION REVIEW (INTERMEDIATE): - Demonstrates expertise of utilization review in practical applications of a difficult nature. Possesses sufficient knowledge, training, and experience to independently complete clinical review to obtain payor authorization. Demonstrates mastery in InterQual Level of Care Criteria and Milliam Care Guidelines. Able to train and educate by setting the example, giving technical instruction, providing leadership, and generally raising the level of performance of others while on the job.
MEDICAL TERMINOLOGY & DOCUMENTATION - (NOVICE): - Possesses sufficient fundamental proficiency to successfully demonstrate medical terminology and documentation in practical applications of moderate difficulty.
INTERDISCIPLINARY EDUCATION (NOVICE): - Seeks to provide education by collaborating with providers and other members of the health care team to ensure that the patient is placed in the appropriate level of care setting.
CLINICAL APPLICATIONS SYSTEMS (NOVICE): - Possesses fundamental proficiency in utilization review systems, clinical support systems and business support applications as needed
Organizational Impact: Independently delivers on objectives with understanding of how they impact the results of own area/team and other related teams.
Problem Solving/ Complexity of work: Utilizes multiple sources of data to analyze and resolve complex problems; may take a new perspective on existing solution.
Breadth of Knowledge: Has advanced knowledge within a professional area and basic knowledge across related areas.
Team Interaction: Acts as a go-to resource for colleagues with less experience; may lead small project teams.
Internal Number: 2000924
About Vanderbilt Health
Vanderbilt University Medical Center is home to Vanderbilt University Hospital, The Monroe Carell Jr. Children’s Hospital at Vanderbilt, the Vanderbilt Psychiatric Hospital and the Vanderbilt Stallworth Rehabilitation Hospital. These hospitals experienced more than 61,000 inpatient admissions during fiscal year 2015. Vanderbilt’s adult and pediatric clinics treated nearly 2 million patients during this same period.Vanderbilt University Hospital and the Monroe Carell Jr. Children’s Hospital at Vanderbilt are recognized again this year by U.S. News & World Report’s Best Hospitals as among the nation’s best with 18 nationally ranked specialties. Vanderbilt University Medical Center is world renowned because of the innovation, work ethic and collegiality of its employees. From our health care advances to our compassionate care, Vanderbilt owes its accomplishments and reputation to staff and faculty who bring skill and drive and innovation to the medical center day after day. World-leading academic departments and comprehensive centers of excellence pursue scientific discoveries and transformational educational and clinical advances across the entire spectrum of health and disease.As th...e largest employer in middle Tennessee, we welcome those who are interested in ongoing development in a caring, culturally sensitive and professional atmosphere. Most of us spend so much of our lives at work, we want to be part of maintaining a workplace in which people support one another and encourage reaching for excellence. Many high-achieving employees stay at Vanderbilt because of the professional growth they experience and because of their appreciation of Vanderbilt’s benefits, public events and discussions, athletic opportunities, beautiful setting and, above all, sense of community and purpose.Vanderbilt and its employees share a set of mutual expectations that have been created with productivity, legality, fairness and safety always in mind. We believe that our investment in training and compensating employees multiplies in value when we enable individuals to deliver their best performance for the benefit of us all.