Utilization Management Specialist

UMass Memorial Health•Worcester, MA

2d•Remote

About The Position

At UMass Memorial Health, everyone is a caregiver – regardless of their title or responsibilities. Exceptional patient care, academic excellence and leading-edge research make UMass Memorial the premier health system of Central Massachusetts, and a place where we can help you build the career you deserve. We are more than 20,000 employees, working together as one health system in a relentless pursuit of healing for our patients, community and each other. And everyone, in their own unique way, plays an important part, every day. The Utilization Management Specialist (UMS) screens patients to determine the appropriate level of care through the use of clinical criteria, the Medicare Inpatient Only List, and individual payer requirements. The Utilization Management Specialist collects data, completes audits, and generates reports based on trends and various improvement initiatives. The Utilization Management Specialist interacts with Care Coordination, Coding, Revenue Integrity, Compliance, Physician Advisors, Physicians, and payers to establish level of care. The UMS Actively participates in the physician Advisor program to assist in the correct LOC, and concurrent denials management.

Requirements

Completion of an accredited school of nursing program.
Current Massachusetts RN licensure and registration.
Two year’s experience in utilization review, case management, or relevant clinical experience.
Knowledge of utilization review practices and principles.
Ability to form positive, collaborative relationships with hospital staff and internal and external partners.
Ability to effectively negotiate with internal and external partners of patient care services.
Ability to assess data reflective of the patient’s status and interpret the appropriate information needed to identify each patient’s requirements relative to his/her age-specific needs and to provide the care they need.
Ability to work independently.
Ability to use specialized computer-based systems for the gathering, reporting, and analysis of clinical data.

Nice To Haves

Bachelor of Science degree in Nursing.

Responsibilities

Reviews admissions to ensure status is appropriate and that authorization has been appropriately obtained and is in compliance with Medicare or other payer requirements standards of care.
Initiates discussions with the attending physician, advanced practice providers (APP), physician advisors, and or case managers for patients who do not meet appropriateness criteria and recommend alternate level of care.
Intervenes with the payer when needed to a resolve denial and level of care issues.
Communicate and facilitate the P2P process between physician advisor and payer physician advisor. Documents outcome.
Documents clinical information necessary to obtain approval from the payer as indicated in the patient medical record.
Documents level of care updates, and billing coding changes in the system applications and work queues to communicate with Revenue Integrity for correct billing.
Determines medical necessity and appropriateness of admission and stay in accordance with level of care screening and utilization of the inpatient only list from Medicare.
Determines medical necessity and appropriateness of admission and stay in accordance with level of care screening for observation and surgical day with extended recovery patients.
Uses established processes to manage all level of care changes.
Works with Revenue Integrity to understand the pre-certification requirements of all contracted payers.
Validates admission criteria with third party payers and Attending Physicians. Recommends alternative care sites where appropriate.
Collaborates with the Revenue Integrity and Denial teams to help to respond to all pre-certification denials while identifying the issues and providing a proactive response. appropriate to pre-certification denials management.
Collaborates with medical staff and case managers to assure accuracy and completeness of patient level of orders, assuring variances from admission standards are identified during the patient admission.
Collaborates with the third-party payers to anticipate denial of payment and proactively addresses issues contributing to a potential denial.
Provides admission, continued stay and discharge clinical review, including clinical reviews, to payers in accordance with established standards, procedures, and policies.
Reviews requests for transfers from other facilities to ensure that the patient’s condition necessitates the transfer and provides feedback to the sending facilities regarding determination.
Communicates potential issues in care needs, reimbursement and/or discharge planning related to individual patients to the appropriate Care Manager and documents same in the patient’s medical record.
Review all Inpatient 1 and 2-day length of stay records to verify patient class and appropriate billing. Makes classification status changes in the EMR as appropriate per payer allowances.
Complies with established departmental policies, procedures, and objectives.
Attends variety of meetings, conferences, seminars as required or directed.
Demonstrates use of Quality Improvement in daily operations.
Complies with all health and safety regulations and requirements.
Respects diverse views and approaches, demonstrates Standards of Respect, and contributes to creating and maintaining an environment of professionalism, tolerance, civility and acceptance toward all employees, patients, and visitors.
Maintains, regular, reliable, and predictable attendance.
Performs other similar and related duties as required or directed.