Utilization Management/CDI Specialist

Description

Responsible for applying clinical and benefits administration policy guidelines to requests for authorizations. 

Provides accurate, prompt, and appropriate medical authorizations to requests for Patients, Insurance Companies, and Providers.

Ensures that clinical documentation complies with federal laws.

Demonstrates the mission of HRMC by displaying REACH, our core value system:

• Respectful - We value the unique talents, ideas, contributions, and circumstances of each individual.
• Engaged - We value being active, positive participants at work and in our communities.
• Available - We value providing local access to care for our communities while being present for each other.
• Competent - We value knowledgeable, people-centered, innovative, and technology driven teams.
• Helpful - We value always helping others with kindness and compassion.

Essential Job Functions:

­ Demonstrates understanding that patients, physicians, visitors, and other hospital staff are customers, and consistently seeks to exceed customers’ expectations.

­ Uses established criteria to conduct preliminary decision review for services requiring prior authorization

­ Applies clinical and benefit administration policy guidelines to requests for authorizations

­ Assesses the need for additional information to complete a service decision request

­ Enters authorizations into the EMR data system to ensure timely review of and downstream claims processing

­ Works closely with Care Coordinator and Medical staff to escalate decisions that require clinical review and oversight

­ Communicates results of reviews in the EMR UR space for the primary care team and clinical reviewers

­ Handles all authorization requests timely and accurately, adhering to performance measures

­ Follows department and organizational policies and procedures as well as adheres to all applicable regulatory, contractual, and compliance requirements

­ Fulfills duties as above within service standard turnaround times

­ Analyzes medical information and trains staff in medical documentation practices

­ Facilitates the Utilization Management Program, Committee, and Plan

Other Job Duties:

­ Promotes and maintains confidentiality of information regarding patients, families, health care personnel and the facility.

­ Participates in hospital's quality, risk and utilization plan.

Qualifications: (Minimum Education and Experience)

­ Associate’s degree or equivalent experience – bachelor’s degree (preferred) 

­ 2 years professional work experience in health care, managed care, or insurance

­ Education, training, or experience as a medical coder, medical billing, Insurance Coordinator or other relevant clinical background highly preferred

Knowledge, Skills, and Abilities:

­ Familiarity with utilization management review preferred

­ Knowledge of CPT and ICD coding highly preferred

­ Flexibility and understanding of individualized care plans

­ Excellent interpersonal, verbal, and written communication skills

­ Ability to work independently and make decisions

­ Work in a team-based environment

­ Working knowledge of and ability to navigate through the healthcare system (insurances, Medicare, Medicaid, physician office operations)