UTIL MGMT SPECIALIST II

Covenant Health•Knoxville, TN

About The Position

Utilization Management Specialist II will perform utilization management functions to include medical necessity reviews to promote a utilization management program. Prepares and reviews necessary documentation for insurance utilization management processes and coordinates communication between members of the UM team to ensure timely follow through for status placement. Collaborates with attending physician if ambiguous documentation pertaining to patient status placement requires clarification. Utilizes electronic utilization management database for documentation of interventions and communications so as to ensure accurate reporting. Collaborates with patient account services, physicians, care coordinators, physician advisors and facility departments as related to utilization management. Communicates with hospital and payor medical directors in order to correctly determine the medical necessity of patient status with a patient advocacy focus. The UM Specialist II problem solves and assists UM department leadership in process improvement/development. The UM Specialist II functions independently when completing all assigned tasks and serves as an internal resource for training needs.

Requirements

None specified; will accept any combination of formal education and/or prior work experience sufficient to demonstrate possession of the knowledge, skill and ability needed to perform the essential tasks of the job, typically such as would be equivalent to a high school diploma or GED.
Prior experience as a UM Specialist I with satisfactory performance evaluations and no written disciplinary actions or at least 2 years of prior UM or equivalent experience.

Nice To Haves

Preference may be given to individuals possessing a HS diploma or GED.
Current Tennessee LPN license is preferred.
Proficiency in an area related to Utilization Management including but not limited to Miliman Care Guideline (MCG) certification, MCG interrater reliability assessments, other healthcare certification or mastery of internally developed educational assessment

Responsibilities

Reviews providers’ requests for services and coordinates utilization management review.
Reviews precertification requests for medical necessity for all payors as applicable, referring to the second level physician reviewer those that require additional expertise.
Maintains accurate records of all communications and interventions related to utilization management.
Sets up communications with payors and/or physicians as applicable.
Collaborates with payor utilization management liaisons and medical directors as applicable.
Reviews all cases received from the registration department to verify that the insurance pre-certification process has been completed in order to meet contractual obligations.
Coordinates execution of notices (denials) of non-coverage related to patient status decisions when appropriate and communicates with key stakeholders to ensure that patient liability is correctly managed.
Intervenes in Peer-to-Peer meetings between physicians and payors as applicable.
Exhibits effective verbal and written communication skills in order to clearly present clinical and financial data to various audiences as necessary.
Completes daily work lists for utilization review meeting the time frames set forth by Covenant Health.
Performs medical necessity screening of clinical information for all payors.
Develops and maintains a professional rapport with physicians and physician office staff.
Performs daily chart reviews for observation hour calculations and observation charge entry in STAR
Performs delayed claims review to determine appropriate number of observation hours as applicable.
Assist with all insurance requested audits and provides information to supervisor related to inaccurate and/or missing documentation as applicable.
Uses effective relationship management, coordination of services, resource management, education, patient advocacy and related interventions to:
Promote patient advocacy
Promote quality of care
Promote cost effective medical outcomes
Promote appropriate admission status
Consistently exhibit a positive relationship by regular collaboration and communication with care management when the UM process impacts the discharge plan.
Exhibits expertise in utilization management including but not limited to:
Knowing Medicare rules and regulations related to utilization
Knowing payor policies related to utilization management
Demonstrates ability to independently locate, interpret and apply regulations with which they may otherwise be unfamiliar.
Knowing Covenant Health’s Policies related to utilization management.
Keeping abreast of current changes affecting utilization management as applicable
Promotes a culture of professional expertise in utilization management by:
Performing utilization management responsibilities with minimal supervision and oversight while making independent decisions.
Maintaining high quality reviews as evidenced by lack of accts hitting the failed bill report, feedback from PAG
Consistently meeting the 95% benchmark on the Outpatient in a Bed report for the reviewer’s primary facility.
Seeking out appropriate educational opportunities and sharing information with department members via staff meetings
Motivates coworkers and promotes a team effort in meeting deadlines with accuracy and professionalism by:
Consistently offering support and assistance to other UM staff members to facilitate timely completion of day to day UM functions
Collaborating with UM leadership to identify and implement process changes that enhance or improve UM processes
Becoming a “super user” of computer applications used including but not limited to Xsolis, Cerner, Star and share best practices with UM dept members
Attends meetings as required and participates on committees as directed or nominated, includes but not limited to the KBOS Culture Team
Takes initiative to perform other related duties as assigned or requested.
Serves as a mentor and assists in training of new employees
Supports, models and adheres to desired behaviors of the KBOS Constitution for caring which are; build a trusting environment by listening with an open mind and valuing different opinions; asking questions for understanding and allowing others to speak openly, do not gossip or criticize people behind their back, resolve conflicts, notice and express appreciation for good work and respect differences by listening with an open mind.
Supports, models and adheres to the desired behaviors of the KBOS Constitution and Covenant Health for service which are; take ownership for our mistakes, resolve customer problems on the spot whenever possible, treat all people with respect and kindness, strive to meet or exceed customer expectations, collect and use customer feedback/data to improve processes and service and set an example for accountability and responsiveness: return e-mail and phone calls promptly, assure deadlines are met, keep commitments.