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

Mount Sinai Health System•New York, NY

1d•Onsite

About The Position

This position 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. The role includes utilization management support functions for patient admissions and continuing stay, as well as facilitating and tracking concurrent adverse determinations and collaborating with the Appeals Management Department in managing retrospective denials.

Requirements

Associates degree or equivalent combination of experience
2 or more years of relevant experience

Nice To Haves

Bachelors preferred

Responsibilities

Communicate with payer to obtain request for clinical information, payer authorization and determination, following up at regular intervals to ensure payer response.
Coordinate peer to peers, ensuring timely scheduling if a case is denied.
Responsible for all relevant communication with payers (time stamped) and entering it into an electronic tracking system.
Process payer denial correspondence mail, end of day reports and faxes.
Enter payer requests, authorization and determination into the tracking system.
Enter required information and tasks into the tracking system to alert Case Managers (CMs) of the need for initial and continued stay reviews.
Process continued stay and admission denials.
Assign denials to the CMs and MD resource as appropriate.
Oversee collection and integrity of all reported data elements (top-level KPI's; process metrics).
Enter all certification and denial data into the tracking system based on review of payer communication.
Enter end of day reports, any notification from internal and external case managers, and financial screening information.
Communicate with PFS and ensure relevant information is available for billing purposes.
Contact insurance companies and set up peer to peer telephone conferences.
Send communication to the group providing peer-to-peer contact number, patient's insurance ID, and DOB.
Responsible for incoming communications via phone or fax and monitoring 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 the electronic tracking systems, the EMR, the finance system and the admitting systems.
Maintain office files, equipment and supplies.
Perform other duties as assigned.