Career Center

Utilization Management Specialist

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.


KEY RESPONSIBILITIES:

• 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.

TECHNICAL CAPABILITIES:

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

CORE ACCOUNTABILITIES:

• 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.