Utilization Management Specialist II

Anmed Gmbh•Anderson, SC

48d

About The Position

This position is responsible for performing the daily operations of the Utilization Management program at AnMed within the Care Coordination model. These duties include but are not limited to initial medical necessity review, continued stay/concurrent review, retrospective review, bed status management, resource utilization management, regulatory compliance, and related denial management issues.

Requirements

Minimum of two years of clinical experience required with current SC license as RN.
Bachelor of Science in nursing.
Excellent communication skills, written and verbal.
Excellent communication skills and computer experience
Ability to work independently and meet deadlines and schedules

Nice To Haves

Utilization management experience.

Responsibilities

Performs assigned utilization management functions daily: initial, concurrent and retrospective review of the medical record with speed and accuracy for all required patient types within defined review standards, including daily review for discharges and transfers.
Uses clinical knowledge to independently review the medical record for clinical appropriateness and resource utilization including but not limited to : patient acuity and related clinical services, applies approved medical necessity criteria for screening of level of care as needed/required, documentation appropriateness/accuracy, and makes recommendation as to appropriateness of clinical level of care e.g. inpatient vs outpatient, documentation accuracy of severity of illness and intensity of services, regulatory compliance with documentation and physician orders.
Reviews all available clinical information per individual case to determine medical necessity, appropriateness of services, and targeted length of stay based on approved criteria and standards.
Communicates /oversees communication of clinical information to required third parties in a timely and knowledge manner within defined review and/or contractual standards.
Initiates peer-to-peer i.e. MD to MD calls with payer physician to avoid denials.