RN UTILIZATION MANAGEMENT SPECIALIST

Covenant HealthCare • Saginaw, MI

3d

About The Position

The Utilization Management Specialist supports the Clinical Resource Management Department and serves as a liaison with external agencies and third-party payers. The role applies approved clinical appropriateness criteria, including InterQual™ Acute Care Criteria, to review admission and continued-stay appropriateness and document findings according to department standards.

The specialist collaborates with case management, physicians, payers, Patient Accounting, Health Information Management, Admitting, and other healthcare team members. The position communicates clinical information to external parties to obtain payer approvals, support efficient use of resources, and secure appropriate reimbursement. The specialist maintains organized databases of payer requirements, reviews, contacts, decisions, appeals, and contract requirements, and reports trends in payer reviews.

The role also manages authorization requests, non-coverage notices, payer denials, and appeals; supports reimbursement and denial-management efforts; and serves as a resource to the healthcare team. The specialist is expected to provide excellent customer service and demonstrate effective communication, negotiation, diplomacy, assertiveness, collaboration, and critical thinking.

Requirements

• Current RN license in the State of Michigan.
• Demonstrated clinical competence.
• Competence in denial and appeals management and utilization management.
• Excellent letter-writing and verbal communication skills.
• Strong understanding of disease processes and treatment regimens associated with designated patient populations.
• Critical-thinking skills and ability to analyze multiple issues affecting outcomes.
• Problem-solving skills and ability to manage multiple situations simultaneously and adjust to frequently changing priorities.
• Strong commitment to collaboration and teamwork, including coordinating assignments with peers.
• Good computer skills.
• Excellent communication, negotiation, diplomacy, and assertiveness skills.
• Solid understanding of the healthcare industry, technology, and regulations.
• Professional approach to work and a strong sense of responsibility for assigned duties.
• Ability to maintain punctual attendance consistent with ADA, FMLA, and other applicable federal, state, and local standards.
• Ability to perform the listed physical activities and occasional lifting of up to 100 or more pounds.

Nice To Haves

• Three years of successful performance in utilization management.

Responsibilities

• Demonstrate excellent customer service and contribute to patient-satisfaction targets.
• Complete medical-necessity reviews for all patients as soon as possible after admission and continued-stay reviews at least every 48 hours, unless InterQual™ criteria or payer requirements indicate otherwise.
• Verify that physician orders, InterQual™ criteria, and the patient class in Epic are compatible.
• Follow EHR referral process guidelines for specified Medicare cases, including cases that do not meet inpatient criteria, inpatient-only list reviews, questioned readmissions, physician-disapproved status changes, and continued stays that no longer meet inpatient criteria.
• Contribute to organizational net operating margin targets and ensure accurate, timely information is available.
• Demonstrate age-specific competency for newborn, infant, pediatric, child, adolescent, adult, and geriatric populations.
• Use technology and electronic information transfer to obtain and deliver clinical information across multidisciplinary areas and obtain authorization for hospital days.
• Confirm that the patient's level of care is supported by signs, symptoms, and treatment for inpatient, ambulatory, obstetric-monitor, and observation stays.
• Negotiate with payers to facilitate reimbursement and obtain authorization for urgent and emergent hospital admissions.
• Assist with governmental agency information requests and prepare and provide reports.
• Collaborate with Patient Accounting, Patient Admission and Registration, Health Information Management, and Finance to optimize reimbursement.
• Use information from Case Management Specialists and identify additional clinical information to communicate to review agencies, including condition, severity of illness, treatment, intensity of service, and plan of care.
• Document and manage third-party payer contacts and certification information, and maintain organized databases of payer requirements and contracts.
• Prepare, issue, distribute, and track notices of non-coverage.
• Serve as an internal resource on reimbursement requirements and strategies, and maintain current knowledge of payer contract requirements and utilization-management implications.
• Demonstrate fiscal responsibility and appropriate use of available resources.
• Complete payer pre-notification and pre-certification for scheduled surgical patients when required.
• Coordinate contacts between physicians and payers.
• Manage and respond to concurrent third-party payer denials involving outpatient and inpatient cases alleged to be medically inappropriate.
• Manage and respond to retroactive Medicaid denials involving inpatient readmission and transfer cases requiring PACE authorizations.
• Serve as a resource to the healthcare team on denial management and utilization management.
• Build effective professional relationships with healthcare team members, interact with physician office staff, facilitate payer meetings, and work to maximize positive outcomes.
• Manage conflict effectively and work collaboratively toward mutually beneficial outcomes.

Benefits

• Comprehensive medical, dental, and vision coverage.
• Retirement plans with employer match.
• Paid time off.
• Employee wellness programs and mental health support.
• Tuition reimbursement, university discounts, and professional development opportunities.

What This Job Offers

• Job Type: Full-time
• Education Level: No Education Listed