Utilization Management Specialist

Genesis Healthcare System

About The Position

In order to fill our Mission of serving our community by helping each person achieve optimal health and well-being by providing compassionate, exceptional, and affordable healthcare services, all employees of Genesis HealthCare System must be committed to living the Genesis Mission and Genesis values of Compassion, Excellence, Integrity, Team, and Innovation. All employees must regard themselves as an ‘owner’ of Genesis and keep our patients at the center of everything we do - always. Position Details: Work Shift: Scheduled Weekly Hours: 24 Department: Patient Account Management Overview of Position: To lead and facilitate strategic aspects of all denials including all initiatives associated with Recovery Audit Contractors (RAC) implementation at Genesis HealthCare System. Monitors overall impact of denials and RAC effect by developing workflows, policies and procedures, and a communication plan to prepare for RAC audits. Manages RAC requests for records, appeals, and revenue adjustments through a tracking system database.

Requirements

Registered Nurse.
3 years in an acute care setting, utilization management, or insurance/hospital case management setting.
Knowledge of InterQual criteria.
Attends an educational program on Hospital Based Coding Guidelines within the 1 year.
Demonstrated knowledge of CPT-HCPCS, modifiers, UB revenue codes, ICD-9-CM diagnosis and procedure coding and Medicare guidelines.
Excellent written and oral skills, attention to detail and follow through.
Ability to organize work, recognize and establish priorities, and complete work without creating backlogs.
Excellent interpersonal, decision-making, facilitation, conflict resolution and investigative skills.
Excellent computer skills and knowledge of computer software, including Word, Excel, PowerPoint, etc.
Ability to work independently and under pressure in a complex and changing working environment.

Responsibilities

Directs, plans, coordinates and oversees specific functions and activities associated with all denials including the RAC audit process.
Writes all level appeal letters, making a case for additional reimbursement.
Oversees the maintenance of the denials and RAC database to assure accurate information is documented.
Assists in the development of RAC policies and procedures approved by the Revenue Cycle Steering Committee.
Functions as the primary RAC liaison for case management, physicians, documentation improvement specialist, clinical and operational departments and patient accounting.
Recommends process or policy changes as necessary to avoid lost revenue as a result of denials/RAC requests/audits.
Analyzes and prepares monthly reports documenting the status of all request/audits and submits to RAC Team members.
Performs final review of records being submitted to the RACs and tracks the appeal process and outcomes for RAC audits.
Researches and maintains regulatory guidelines applicable to coding/medical necessity as needed for defense purposes relative to the RAC audits.
Works directly with physician advisor to educate physicians on utilization, medical necessity, and documentation improvement.