UTILIZATION PAYOR SPECIALIST RN

HHC•Indianapolis, IN

10d

About The Position

The Utilization Payor Specialist, RN is responsible for working behind the scenes to maximize the quality and cost of efficiency of health services. This position coordinates pre-certifications, re-certifications, the denial management and appeals process, and initial and concurrent reviews. Through regular reviews and audits, the Utilization Payor Specialist ensures that patients receive the care needed without burdening the health care system with unnecessary procedures, ineffective treatments or lengthy hospital stays.

Requirements

Current Indiana RN nursing license required
Four years of clinical nursing experience required
Must demonstrate knowledge of the Utilization Management managed care processes
Must demonstrate knowledge of levels of care of Inpatient and Outpatient status
Excellent interpersonal, written and verbal communication, and negotiation skills
Demonstrated ability to be diplomatic and flexible, and demonstrates a high level of professionalism
Ability to cohesively network with the Interdisciplinary Team

Nice To Haves

Two or more years of Utilization Review experience strongly preferred

Responsibilities

Communicates secondary review decisions determining appropriate patient status provided by secondary reviewer process
Communicates and negotiates with payers to obtain approvals for the appropriate care level
Serves as a resource on payor requirements for severity and intensity of service determinations for outpatient and acute inpatient admissions
Provides timely payor feedback to Case Managers and Social Workers; notifies the Case Manager when additional clinical information may be required that is not currently identified within the electronic medical record or bedside documentation to ensure that services will be approved at the acute level of care as required by the payor
Ensures pre-certification/authorizations for post-acute services, initial, concurrent reviews, authorizations not obtained by Patient Registration/Admitting or the doctor's office and clinics for direct admissions and procedures
Reviews patient admission for appropriateness and type; refers case to Medical Director/department leadership for review and course of action when case fails to meet admission standards
Coordinates and facilitates the most accurate and appropriate patient status for care across the continuum
Actively communicates and documents payor issues and concerns regarding the initial level of care, continued stay, denials and discharge plans to the Medical Director/department leadership as appropriate
Supports the denial management process and participates in tracking and reporting denials
Ensures payor and customer satisfaction through effective communication with the Interdisciplinary Team
Obtains payor certification for unplanned admissions, homecare and post-acute services as required
Initiates contact with payers for continued stay; reviews utilizing clinical information; pursues additional information as needed
Utilizes conflict resolution, critical thinking, and negotiation skills as necessary to ensure timely resolution of issues
Identifies concurrent third-party payers denials and notifies Case Managers for immediate intervention and escalation to the Medical Director/department leadership
Coordinates denial and appeals process and responds to all third-party payer denials
Applies appropriate clinical criteria to complete initial reviews within 24-48 hours of patient presentation
Facilitates tracking and payment approval processes for the outpatient parenteral antimicrobial therapy program (OPAT)
Assists with coordination, data entry and needed follow up support to the OPAT program
Provides post-hospitalization telephonic follow up for OPAT patients in the community for care coordination regarding care outcomes that support the OPAT program
Facilitates tracking and payment approval processes for Eskenazi Health inpatient overlaps receiving services at IUH
Facilitates tracking and payment approval processes for Eskenazi Health Cardiac send-out receiving services at IUH
Reviews claims for both inpatient overlaps and cardiac send-outs and verifies dates of service; provides to Revenue Cycle for adjudication and payment
Facilitates tracking and payment approval processes for vendor picc lines to include charge reconciliation in EPIC
Provides oversight and maintains readmission initiatives directly related to Target Diagnosis, Bedside education, follow-ups for vendor-automated calls
Provides assistance for complex discharge planning placement and programs, departmental projects, authorizations and accounts payable
Facilitates referral, tracking and payment approval processes for Eskenazi Health requiring home wound-vac services provided by in-network vendors for specialty clinics and patients discharging home