Utilization Specialist

Erlanger Health System; Hudson (WI); Sur place; USD 50 000 - 70 000; Plein temps

Résumé du poste

Erlanger Health System is seeking a utilization management professional to proactively monitor patient service utilization and optimize reimbursement for the facility.

The role involves acting as a liaison between managed care organizations and clinical staff, conducting reviews for certification requirements, and coordinating communications related to reimbursement. Experience in utilization management is preferred and clinical experience is required.

Qualifications

• High school diploma or equivalent required.
• Preferred degrees in Social Work, Behavioral or Mental Health, Nursing, or related health field.
• Clinical experience required, or 2+ years working with facility population; utilization management preferred.

Responsabilités

• Act as liaison between managed care organizations and facility clinical staff.
• Review insurance plans for certification requirements and coordinate communication on reimbursement.
• Monitor length of stay and inform staff of issues affecting stay.
• Gather and report statistics on utilization, discharges, and quality of services.
• Conduct quality reviews for medical necessity and services.

Connaissances

Communication

Interpersonal skills

Healthcare reimbursement

Quality review

Formation

High school diploma or equivalent

Associate/Bachelor/Master in health-related field

Outils

None

Description du poste

Overview

Proactively monitor utilization of services for patients to optimize reimbursement for the facility.

PURPOSE STATEMENT:

Responsibilities

ESSENTIAL FUNCTIONS:

• Act as liaison between managed care organizations and the facility professional clinical staff.
• Conduct reviews, in accordance with certification requirements, of insurance plans or other managed care organizations (MCOs) and coordinate the flow of communication concerning reimbursement requirements.
• Monitor patient length of stay and extensions and inform clinical and medical staff on issues that may impact length of stay.
• Gather and develop statistical and narrative information to report on utilization, non-certified days (including identified causes and appeal information), discharges and quality of services, as required by the facility leadership or corporate office.
• Conduct quality reviews for medical necessity and services provided.
• Facilitate peer review calls between facility and external organizations.
• Initiate and complete the formal appeal process for denied admissions or continued stay.
• Assist the admissions department with pre-certifications of care.
• Provide ongoing support and training for staff on documentation or charting requirements, continued stay criteria and medical necessity updates.

OTHER FUNCTIONS:

• Perform other functions and tasks as assigned.

Qualifications

EDUCATION/EXPERIENCE/SKILL REQUIREMENTS:

• Required Education: High school diploma or equivalent.
• Preferred Education: Associate's, Bachelor's, or Master’s degree in Social Work, Behavioral or Mental Health, Nursing, or a related health field.
• Experience: Clinical experience is required, or two or more years' experience working with the facility's population. Previous experience in utilization management is preferred

LICENSES/DESIGNATIONS/CERTIFICATIONS:

• Preferred Licensure: LPN, RN, LMSW, LCSW, LPC, LPC-I within the state where the facility provides services; or current clinical professional license or certification, as required, within the state where the facility provides services.
• CPR and de-escalation and restraint certification required (training available upon hire and offered by facility.
• First aid may be required based on state or facility requirements.

ADDITIONAL REGULATORY REQUIREMENTS:

While this job description is intended to be an accurate reflection of the requirements of the job, management reserves the right to add or remove duties from particular jobs when circumstances (e.g. emergencies, changes in workload, rush jobs or technological developments) dictate.

We are committed to providing equal employment opportunities to all applicants for employment regardless of an individual’s characteristics protected by applicable state, federal and local laws.

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