What are the responsibilities and job description for the UM Quality Review Specialist position at Gonzaba Medical Group?
Job Details
UM Quality Review Specialist
General Summary: UM Quality Review Specialist focuses on overall quality, compliance, auditing activities which
include retrospective review process at GMG, though also may help with concurrent and prospective reviews. Work with delegated teams (Utilization Management (UM), Claims, Network Development, Credentialing, Administrative Audits) to ensure readiness, well documented evidence, and reporting and policies are put in place. Assists with the submission of the Delegation documents. Helps to ensure UM delegation is being carried out correctly in GMG’s daily operations, and that completion of reviews performed timely, and as efficiently / effectively as possible.
Supervisory Responsibilities: This position has no supervisory responsibilities.
General Requirements: All duties performed will be done accurately and in a timely manner.
- Exercise tact and courtesy when dealing with patients, visitors, providers, and co-workers.
- Participates in educational programs as needed.
- Maintains strict confidentiality practicing HIPAA rules and regulations.
- Other duties as assigned.
- Provides regular follow-up with delegates for completion of corrective action plans and improvement action plans.
- Must always adhere to customer service expectations including in-person and virtual (via telephone, or telehealth applications) communication.
- Assumes responsibility for maintaining clinical competencies according to Gonzaba Medical Group policy.
Essential Job Responsibilities:
- Oversees any Corrective Action Plan development and submissions, tracking responses, and scoring with delegated health plans.
- Monitoring ongoing audits, improvement actions and overall oversight of required audits.
- Obtains clinical information for the UM nurse to facilitate medical necessity reviews and documents appropriately in review summary.
- Provides regular follow-up with delegates for completion of corrective action plans and improvement action plans.
- Reviews reports daily that document services discovered in the claims process that do not have appropriate authorization to process the claim.
- Research services by various means (review of medical record, consult notes, patient input) to assist the UM nurse in determining if claims should be authorized for payment or denied based on appropriate guidelines.
- Carries out claims process in a timely manner resolving the majority of claims without authorizations within time standards set by department leadership.
- Holds regular “U Status” meetings (U=unauthorized) with referral/MSO team to review complex services, develop consistency in reviews and criteria utilized.
- Demonstrates understanding necessary to assess, review and apply criteria from Medicare
Guidelines, CMS criteria, medical policy, and health plan specific criteria.
- Participates in the annual review of Managed Care, UM policies and procedures, and other
periodic reviews as needed.
Education and Training: High School diploma. Must have knowledge of medical terminology, anatomy, physiology. Familiarity with health care systems, regulations, policies, and functions. Must have a good understanding of documentation standards.
Experience: Requires at least 2 years’ experience in Managed Care/Utilization Management experience.
Experience in a clinic, doctor’s office, or hospital with a minimum of one-year acute care experience.
Other Requirements: Computer Skills: Skilled in use of computer/EMR systems. Knowledge of Word processing software, spreadsheet software, Internet, and database software.
Work Environment: Office environment. Exposure to communicable diseases, bodily fluids, toxic substances, ionizing radiation, medicinal preparations, and other conditions common to a clinic environment.
Mental / Physical Requirements: Requires manual dexterity, sitting, standing, stooping, reaching, kneeling, crouching, bending, walking, lifting up to 40 lbs. without assistance. Close vision and ability to adjust focus. Must be able to work efficiently under pressure.
Additional Information: Gonzaba Medical Group is seeking team members who contribute as A-Players, demonstrate a strong work ethic, are committed to the culture and our core values.
Other Duties As Assigned: The above job description is not intended to be an all-inclusive list of duties and standards of the position. Team members will follow any other instructions, and perform any other related duties, as assigned by their supervisor. Responsibilities, knowledge, skills, abilities, and work environments may change as needs evolve.
