Utilization Management Specialist-MSH-Case Management-FT-Days

About the position

The Utilization Management Specialist at Mount Sinai Health System is responsible for coordinating requests for clinical information from third-party payers and providing support to a broad client base, both internal and external to the institution. This position involves utilization management support functions for patient admissions and continuing stay, facilitating and tracking concurrent adverse determinations, and collaborating with the Appeals Management Department in managing retrospective denials.

Responsibilities

• Communicate with payer to obtain requests for clinical information, payer authorization, and determination.
• Follow up at regular intervals to ensure payer response.
• Coordinate peer-to-peer communications if a case is denied.
• Responsible for all relevant communication with payers and enter data into the electronic tracking system.
• Process payer denial correspondence and end-of-day reports.
• Enter payer requests, authorizations, and determinations into the tracking system.
• Alert case managers of the need for initial and continued stay reviews.
• Oversee collection and integrity of all reported data elements.
• Communicate with Patient Financial Services (PFS) to ensure relevant information is available for billing.
• Contact insurance companies to set up peer-to-peer telephone conferences.
• Monitor incoming communications via phone or fax and manage office voice mails.
• Fax denial letters to the centralized MSHS denial department within 48 hours of receipt.
• Generate and distribute payer Census Logs to external clients.
• Prioritize incoming communications and relay messages to Case Managers or other UM staff.
• Perform other daily tasks associated with data entry and reconciliation between electronic tracking systems.

Requirements

• Associate degree required.
• Bachelor's degree with coursework in business preferred.
• Familiarity with Third Party Payor requirements preferred.