Utilization Mgmt Specialist

Valley Medical Center Renton , WA 98055

Posted 3 months ago

JOB DESCRIPTION:

POSITION TITLE: Utilization Management Specialist [On Call

  • Hourly] JC- 4150

JOB OVERVIEW: Responsible to oversee the completion of utilization review duties in a timely manner and in accordance with organizational priorities.

ROLE: Refer to Administrative Partner job description.

ASSIGNMENT AREA: Outcomes Management

HOURS OF WORK: 8:00 am

  • 4:30 pm Monday

  • Friday as assigned including limited weekend and holiday rotation with some flexibility in start and stop times; may be requested to work part shifts.

RESPONSIBLE TO: Manager Comprehensive Care Coordination

PREQUISITES:

  • Current license in the state of Washington as an RN (Bachelors degree preferred) or LPN, or

  • Bachelors degree in Social Work (Masters degree preferred) with previous UR experience required.

  • Previous health care review experience preferred for RNs/LPNs preferred.

  • Experience using online InterQual and Milliman Guidelines preferred.

  • Minimum of three years clinical experience in an acute care hospital setting required.

  • Computer literacy (MS Outlook, Word, Excel) required.

  • Ability to communicate verbally and in writing fluently in English in an effective manner.

  • Ability to spell accurately and write legibly.

QUALIFICATIONS:.

  • Familiarity with criteria used to determine appropriateness for acute care hospitalization.

  • General familiarity with medical record coding.

  • General knowledge of third party payer review and reimbursement systems and utilization monitoring requirements.

  • General knowledge of the DRG system.

  • Ability to set priorities, produce accurate work, and meet deadlines.

  • Ability to function in a setting with a wide variety of duties and numerous interruptions.

  • Neat and well groomed appearance.

UNIQUE PHYSICAL/MENTAL DEMANDS, ENVIRONMENT, AND WORKING CONDITIONS: See Generic Job Description/Administrative Partner

PERFORMANCE RESPONSIBILITIES:

A. Generic Job Functions: See Generic Job Description/or Administrative Partner

B. Unique Job Functions:

  • Review patients for appropriateness of admission, continued stay or readmission using Milliman and InterQuals criteria for severity of illness and intensity of services.

  • Refer all Medicare inpatient admissions who do not met InterQual adult inpatient criteria and all Medicare observation patients to Executive Health Resources (EHR) for concurrent physician review of medical necessity.

  • Provide admission, concurrent and retrospective review information to external review and payer organizations in accordance with VMCs priorities and contracts.

  • Anticipate patient's length of stay, treatment plans and outcomes based upon clinical knowledge, experience and length of stay guidelines.

  • Work collaboratively with other disciplines including, but not limited to, physicians, staff nurses, case managers and social workers to facilitate appropriate resource utilization in the provision of safe patient care.

  • Participate in discharge rounds/patient care conferences as indicated.

  • Communicate with physicians regarding appropriateness of admission/readmission, continued stay and cost containment issues.

  • Refer quality, infection control and risk management issues to appropriate individual or department.

  • Inform physician and Patient Business Office staff of potential admission, continued stay and reimbursement denials.

  • Complete non-governmental payer forms (patient status changes) for reimbursement.

  • Deliver Hospital Issued Notices of Non-coverage (HINN) letters when indicated.

  • Enter accurate and timely utilization management information in STAR UM and denial information in MedAssets.

  • Assist EHR as requested with appeal letters when reimbursement denials do not address medical necessity.

  • Function as preceptor in new departmental employee orientation.

  • Educate physicians and other disciplines about InterQual and Milliman criteria and application.

  • Collect and report statistics as requested by manager.

  • Maintain confidentiality of patient medical records and financial information.

  • Perform other duties as assigned to support accurate and timely provision of utilization management services and patient account management.

  • Provide suggestions regarding quality improvement opportunities to manager.

  • Demonstrate awareness of the importance of cost containment for the department.

Job Qualifications:

PREQUISITES:

  • Current license in the state of Washington as an RN (Bachelors degree preferred) or LPN, or

  • Bachelors degree in Social Work (Masters degree preferred) with previous UR experience required.

  • Previous health care review experience preferred for RNs/LPNs preferred.

  • Experience using online InterQual and Milliman Guidelines preferred.

  • Minimum of three years clinical experience in an acute care hospital setting required.

  • Computer literacy (MS Outlook, Word, Excel) required.

  • Ability to communicate verbally and in writing fluently in English in an effective manner.

  • Ability to spell accurately and write legibly.

QUALIFICATIONS:.

  • Familiarity with criteria used to determine appropriateness for acute care hospitalization.

  • General familiarity with medical record coding.

  • General knowledge of third party payer review and reimbursement systems and utilization monitoring requirements.

  • General knowledge of the DRG system.

  • Ability to set priorities, produce accurate work, and meet deadlines.

  • Ability to function in a setting with a wide variety of duties and numerous interruptions.

  • Neat and well groomed appearance.

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Utilization Mgmt Specialist

Valley Medical Center