Job description

JOB DESCRIPTION

POSITION TITLE: Utilization Management Specialist [On Call - Hourly] JC- 4150
JOB OVERVIEW: Responsible to oversee the completion of utilization review duties in a timely manner and in accordance with organizational priorities.

ROLE: Refer to Administrative Partner job description.

ASSIGNMENT AREA: Outcomes Management

HOURS OF WORK: 8:00 am - 4:30 pm Monday - Friday as assigned including limited weekend and holiday rotation with some flexibility in start and stop times; may be requested to work part shifts.
RESPONSIBLE TO: Manager Comprehensive Care Coordination

PREQUISITES:
Current license in the state of Washington as an RN (Bachelors' degree preferred) or LPN, or
Bachelor's degree in Social Work (Master's degree preferred) with previous UR experience required.
Previous health care review experience preferred for RN's/LPN's preferred.
Experience using online InterQual and Milliman Guidelines preferred.
Minimum of three years clinical experience in an acute care hospital setting required.
Computer literacy (MS Outlook, Word, Excel) required.
Ability to communicate verbally and in writing fluently in English in an effective manner.
Ability to spell accurately and write legibly.

QUALIFICATIONS: .
Familiarity with criteria used to determine appropriateness for acute care hospitalization.
General familiarity with medical record coding.
General knowledge of third party payer review and reimbursement systems and utilization monitoring requirements.
General knowledge of the DRG system.
Ability to set priorities, produce accurate work, and meet deadlines.
Ability to function in a setting with a wide variety of duties and numerous interruptions.
Neat and well groomed appearance.

UNIQUE PHYSICAL/MENTAL DEMANDS, ENVIRONMENT, AND WORKING CONDITIONS: See Generic Job Description/Administrative Partner

PERFORMANCE RESPONSIBILITIES:
A. Generic Job Functions: See Generic Job Description/or Administrative Partner

B. Unique Job Functions:
Review patients for appropriateness of admission, continued stay or readmission using Milliman and InterQual's criteria for severity of illness and intensity of services.
Refer all Medicare inpatient admissions who do not met InterQual adult inpatient criteria and all Medicare observation patients to Executive Health Resources (EHR) for concurrent physician review of medical necessity.
Provide admission, concurrent and retrospective review information to external review and payer organizations in accordance with VMC's priorities and contracts.
Anticipate patient's length of stay, treatment plans and outcomes based upon clinical knowledge, experience and length of stay guidelines.
Work collaboratively with other disciplines including, but not limited to, physicians, staff nurses, case managers and social workers to facilitate appropriate resource utilization in the provision of safe patient care.
Participate in discharge rounds/patient care conferences as indicated.
Communicate with physicians regarding appropriateness of admission/readmission, continued stay and cost containment issues.
Refer quality, infection control and risk management issues to appropriate individual or department.
Inform physician and Patient Business Office staff of potential admission, continued stay and reimbursement denials.
Complete non-governmental payer forms (patient status changes) for reimbursement.
Deliver Hospital Issued Notices of Non-coverage (HINN) letters when indicated.
Enter accurate and timely utilization management information in STAR UM and denial information in MedAssets.
Assist EHR as requested with appeal letters when reimbursement denials do not address medical necessity.
Function as preceptor in new departmental employee orientation.
Educate physicians and other disciplines about InterQual and Milliman criteria and application.
Collect and report statistics as requested by manager.
Maintain confidentiality of patient medical records and financial information.
Perform other duties as assigned to support accurate and timely provision of utilization management services and patient account management.
Provide suggestions regarding quality improvement opportunities to manager.
Demonstrate awareness of the importance of cost containment for the department.

PREQUISITES:
Current license in the state of Washington as an RN (Bachelors' degree preferred) or LPN, or
Bachelor's degree in Social Work (Master's degree preferred) with previous UR experience required.
Previous health care review experience preferred for RN's/LPN's preferred.
Experience using online InterQual and Milliman Guidelines preferred.
Minimum of three years clinical experience in an acute care hospital setting required.
Computer literacy (MS Outlook, Word, Excel) required.
Ability to communicate verbally and in writing fluently in English in an effective manner.
Ability to spell accurately and write legibly.

QUALIFICATIONS: .
Familiarity with criteria used to determine appropriateness for acute care hospitalization.
General familiarity with medical record coding.
General knowledge of third party payer review and reimbursement systems and utilization monitoring requirements.
General knowledge of the DRG system.
Ability to set priorities, produce accurate work, and meet deadlines.
Ability to function in a setting with a wide variety of duties and numerous interruptions.
Neat and well groomed appearance.

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