UTILIZATION MANAGEMENT SPECIALIST

Covenant HealthCare

US:MI:SAGINAW

7:00 PM - 7:12 AM, WEEKENDS REQUIRED

OCCASIONAL

Summary: 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. 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 resources, 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 reimbursement 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 coordinators and others on reimbursement requirements and strategies for success 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 related 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, analyzing multiple issues impacting outcomes Excellent problem solving 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

NOTICE REGARDING LATEX SENSITIVITY IN APPLICANTS FOR EMPLOYMENT.

I t has been determined that Covenant HealthCare cannot provide a latex safe or latex free work environment at any of its facilities. Unfortunately, that means that any individual, including an applicant or an employee, is likely to be exposed to latex while on Covenant’s premises. Therefore, latex tolerance is considered to be an essential function for any position with Covenant.