UTILIZATION MGT SPEC
Location: Saginaw Michigan
Description: Covenant HealthCare is looking of UTILIZATION MGT SPEC right now, this job will be placed in Michigan. More complete informations about this job opportunity please read the description below. Full Time Day Position
Shift: 1
8:00 AM - 4:30 PM, MONDAY - FRIDAY
COOPER CAMPUS, US: MI: SAGINAW
Job description:
The Utilization Management Specia! list demonstrates excellent customer service performance in that his/her attitude and actions are at all times consistent with the standards contained in the Vision, Mission and Values of Covenant and the commitment to Keeping our Promise of Caring. The Utilization Management Specialist demonstrates excellent customer service performance in that his/her attitude and actions are at all times consistent with the standards contained in the Vision, Mission and Values of Covenant and the commitment to Keeping our Promise of Caring. This individual provides support for the Case Management Program by serving as a liaison with external agencies and third party payers. Responsibility includes collaborating with Case Coordinators, physicians, payers, Patient Accounting, Health Information Management, Admitting, and other members of the health care team, and communicating with external parties to achieve desired outcomes for obtaining payer approval for efficient utilization of resour! ces, and appropriate reimbursement of care and services. This ! individual maintains current organized databases regarding payer requirements, payer reviews, contacts, decisions and appeals, and reports trends relative to third party payer reviews.
Responsibilities:
Contributes to organization success targets for patient satisfaction by meeting the Utilization Review Specialist Expectations for Customer Satisfaction
Contributes to organization success targets for net operating margin
Ensures the availability of accurate and timely information
Utilizes latest technology to obtain information from multi-disciplinary areas to obtain authorization of days for a patient’s stay in the hospital
Facilitates delivery of clinical information, i.e. electronic transfer
Assures that patient’s level of care is reflected by the signs, symptoms, and treatment delivered for inpatient, Ambulatory, Obstetrics monitor, and Observation stays
Negotiates with payers to facilitate re! imbursement
Assists with governmental agency requests for information and prepares / provides reports
Works collaboratively with Patient Accounting, Patient Admission and Registration, HIM, and Finance Department to optimize reimbursement
Obtain payor authorization for reimbursement on Urgent and Emergent hospital admissions
Acts as a final gatekeeper for the CRM case management specialist on criteria application prior to payor contacts
Utilizes information provided by the case coordinators, and identifies additional information to communicate to review agencies about patient’s condition and severity of illness, treatments and intensity of service, and plan of care
Documents and manages third party payer contacts and certification information
Maintains an organized database of payor requirements and contracts
Prepares, issues, distributes, and tracks notices of non-coverage
Educates case coor! dinators and others on reimbursement requirements and strategies for su! ccess
Reviews utilization management ramifications of third party payer contracts and maintains current knowledge of contract requirements
Works with the healthcare team to demonstrate fiscal responsibility by being conscious of the need to appropriately use the resource dollars available
Maintains flexibility to changes in delivery of clinical information, i.e. electronic transfer
Completes payor pre-notification / pre-certification to obtain approval authorization for scheduled surgical patients
Coordinates contact between physician and payors
Manages and responds to concurrent third party payer denials of outpatient and inpatient cases alleged to be medically inappropriate, e.g.days of care, services, entire stays, etc
Manages and responds to Medicaid denials of inpatient cases retroactively on readmission and transfer cases requiring PACE authorizations
Serves as a resource to the health care team r! elated to denial management and utilization management
Demonstrates excellent communication skills, negotiation skills, diplomacy and assertiveness
Builds and nurtures professional, effective relationships with all members of the Healthcare team
Manages conflict effectively, striving for win-win outcomes
Serves as a liaison that interacts with physician office staffs and facilitates meetings with payers, and works to maximize positive outcomes
Maintains current knowledge by attending conferences, seminars and reads journal or research articles
Other information:
Education
RN with current license in State of Michigan required
Skills
Demonstrates excellent customer service
Demonstrates competence in denial/appeals management and utilization management
Excellent letter writing and verbal communication skills required
Demonstrates critical thinking skills, anal! yzing multiple issues impacting outcomes
Excellent problem sol! ving skills and the ability to manage many situation simultaneously. Able to adjust to priorities that may change minute by minute
Demonstrates good computer skills
Demonstrates excellent communication skills, negotiation skills, diplomacy and assertiveness
Able to sit for extended periods of time
Able to be on feet and walk for extended periods of time
Able to lift, bend, and carry
Credentials
RN with current license in State of Michigan required
Experience
3 years successful performance in utilization management required
Demonstrated clinical competence
Has exceptional understanding of the disease process and treatment regimens associated with designated patient populations
Strong commitment to collaboration and teamwork, with demonstrated ability to work as a member of a team where assignments must be coordinated with peers
Has a solid understanding of the! Healthcare industry, technology and regulations
A professional approach to work, including a strong sense of responsibility for assigned duties
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If you were eligible to this job, please email us your resume, with salary requirements and a resume to Covenant HealthCare.
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This job starts available on: Wed, 30 Oct 2013 08:26:47 GMT