Rn/Lpn - Utilization Management Specialist / Analyst (64825)

JOB SUMMARY

The utilization management specialist/analyst is responsible for supporting utilization management functions for more complex cases, as needed. Completes utilization reviews for medical necessity, as needed.

Reviews acute inpatient cases, communicating needs related to billing and coding issues. Timely completes accommodations and adjustments, as indicated. Ensures patient status orders are entered timely.

Works with payers to obtain information needed, to avoid delays in payment. Collaborates often with members of the healthcare team, as well as partners from various Hamilton departments. The utilization management specialist/analyst will also assist, as needed, as the case management point of contact for clinical denials and appeal inquiries.

The utilization specialist/analyst will review each case identified/referred for appeal, based on InterQual and/or other relevant guidelines, determine the viability of the appeal, and assist in the appeal process. Working with Case Management leadership, the utilization management specialist/analyst will orchestrate education, complete focused audits, gather data for reporting, extracts data for analysis and interpretation, and other performance improvement initiatives to impact clinical quality, improve efficiency and mitigate lost revenue related to medical necessity denials. The utilization management specialist/analyst will also work with case management leadership, ensuring case management functions are completed per policies, procedures, and in accordance to the requirements of Centers for Medicare and Medicaid Services (CMS), the Joint Commission (TJC), and Georgia Department of Community Health (DCH).

Serves as an active member of the Utilization Management Committee, and regularly report Key Performance metrics.

Qualifications

JOB QUALIFICATIONS

Education: Licensed Practical Nurse or Registered Nurse. Licensed Practical Nurse, must have a strong background in utilization review acute inpatient, with at least 3 years of directly related work experience.

Licensure: Current LPN or RN Nursing license in the State of Georgia or hold a license in the state of their residence, if the state participating in the Nurse Licensure Compact Law, required.

Certification: Interqual and/or Milliman certification preferred. Certified professional coder preferred, or will obtain within 12 months of hire.

Experience: Two to four years of Utilization Review/Management.

Understands the complexity of acute care facilities. Must have 3-5 years of clinical experience/knowledge, in an acute care setting. Must have knowledge of utilization review utilizing InterQual quidelines.

Computer skills / experience, required. Must have an understanding of billing and coding guidelines. Leadership, preceptor and / or project management experience, and data analysis preferred.

Experience with managed care, utilization review, a plus. Experience with accreditation and regulatory guidelines, understanding the importance.

Skills and Personal Qualities:

• Evidence of willingness and ability to assume additional and/or different responsibilities

• Highly motivated, self-directed individual with demonstrated understanding of acute care utilization review issues, including nationally recognized criteria.

• Excellent verbal and written communication skills, strong listening skills, critical thinking and analytical skills, problem solving skills, ability to set priorities and multi-task.

• Proficient in word processing and spreadsheets, and adept at learning new software systems.

• Understanding of Medicare, Medicaid and third party reimbursement methodologies.

• Excellent organizational and analytical skills.

• Ability to communicate with multiple levels in the organization (e.g. managers, physicians, clinical and support staff).

• Demonstrates good role model qualities, ability to effectively interpret, implement, and support approved hospital policies, regulations, philosophy and objectives.

• Ability to maintain a strong relationship with the medical staff and work collaboratively to positively effect clinical and financial outcomes.

PHYSICAL, MENTAL, ENVIRONMENTAL AND WORKING CONDITIONS

Works in a typical acute health care setting with adult, geriatric, newborn, special care nurseries, pediatric patients and families experiencing a wide range of medical and/or surgical problems. Manual and finger dexterity and eye-hand coordination is necessary.

Requires corrected vision and hearing to normal range. Requires working under stressful conditions. Requires working with computers. Requires prolonged periods of time spent on the telephone.