Inpatient Utilization Management Specialist

Group Health Cooperative•Altoona, PA

About The Position

With minimal supervision the Inpatient Utilization Management Specialist assesses, plans, directs, and conducts utilization reviews, discharge planning and transition of care to optimize health care outcomes for our members. Reviews are conducted using evidence-based clinical criteria to determine if admissions and services are medically necessary and a covered benefit under the members health plan. The UM Inpatient Specialist functions as part of an interdisciplinary team. Communicates and documents review determinations in accordance with established policy/procedures, applicable state, federal and accreditation requirements. Relates effectively with others both internally and externally for continuity of care; maintains satisfactory relations with others, maintains accurate and complete records.

Requirements

Registered nurse (R.N.) with a valid license or experience or education.
Must demonstrate high degree of customer service skills, including excellent verbal and written communication skills.
Must be able to work under pressure with strong attention to detail.
Ability to learn and adapt in a changing environment with changing priorities.
Ability to work with and influence a diverse population.

Nice To Haves

Experience conducting medical reviews within medical, behavioral health and/or long-term care environments is preferred.

Responsibilities

Processes prior authorization and pre-certification requests using tools and resources to determine whether the proposed services meet the clinical requirements for medical necessity, appropriate level of care, health plan benefit coverage, network status, and accuracy.
Displays initiative and competence in problem-solving, prioritizing tasks, and managing overall workload.
Consults and reviews with Market Leader, CMO, as necessary.
Embraces change with a positive attitude.
Plans and implements strategies to reduce length of stay and to ensure hospital admissions are medically necessary according to national guidelines.
Advocates on behalf of the member regarding accessibility, type, and quality of services within the benefit structure to provide possible solutions to best meet the member’s needs.
Works in collaboration with hospital staff and member to ensure discharge and transition of care needs of the member are met.
Identify quality events through the utilization review process.
Assists member with education needs and in understanding their discharge plan.
Communicates effectively with co-workers as well as providers regarding continuity of care, including discharge planning.
Attends professional workshops, seminars, and in-service training; transfers knowledge to co-workers.
Participates in identifying process areas for improvement, possible solutions, and leads or assists in implementing changes.
Maintains member confidentiality by following GHC standards, including HIPAA.
Displays empathy and compassion while maintaining policy and benefit specifics.
Works well independently and as part of a team. Is helpful, approachable, and team oriented.
Maintains good rapport with colleagues, ancillary departments, members, and providers.
Completes reviews with timeliness and accuracy of decision-making.
Maintains accurate documentation.
Maintains a professional demeanor when accepting and prioritizing urgent requests.