Utilization Management Specialist

Job Summary:

Med Star Health is looking for a Utilization Management Specialist to join our team! We are looking for someone with knowledge of databases and business software applications, as well as critical thinking and problem-solving skills.

The Utilization Management Specialist will support the concurrent and retrospective utilization management process by collaborating with payors, Med Star Financial Services, and Case Management staff to assure certification and payment of acute care days. Participates in the analysis of denial outcomes data that includes the financial, utilization, performance, and quality improvement activities. Assists in developing new databases for capturing denial and utilization review management.

Join one of the largest healthcare systems in the Baltimore-Washington metro region, also recognized as one of the "Healthiest Maryland Businesses".

• Analyzes and interprets data to provide consistent, meaningful information for the Denials Management Team and specific service lines as indicated. Presents data in a comprehensive format to facilitate understanding and support the decision-making process. Synthesizes and translates data into useful information that can assist service lines enhance their performance.
• Collaborates with Finance, PFS (Patient Financial Services), Operations, and hospital service lines to develop and facilitate the electronic gathering of appropriate denial/appeal and performance measurement data. Supports development and generation of performance reports.
• Develops, maintains, and updates databases to assist the Clinical Review Nurses in the Case Management department with data capturing, monitoring, and reporting activities stemming from their medical record reviews. Maintains confidentiality of all interdepartmental correspondence. Effectively communicates clinical information and negotiates with payors to obtain authorization for appropriate level of care and length of stay. Documents interactions/ interventions.
• Maintains Care Management and performance improvement databases. Monitors consistency, validity, and reliability of data. Maintains, updates, and runs reports from current databases used to collect denial and utilization management data. Generates routine and ad hoc data on resource utilization and outcome measures from information databases. Measures change and trends. Prepares trended reports/presentation for denials management team (Appeals Coordinator).
• Proactively identifies any concerns (e.g., denials, certification status) or change in payor information to Case Manager to concurrently obtain certification of acute days. Streamlines data management processes while gathering utilization management information. Tracks specific denial information for specific departments:
  Case Management (denied days, utilization review) and other departments/services as needed. Supports performance improvement teams to improve processes by generating performance improvement outcome analysis.

• High School Diploma or GED.
• Knowledge of third-party reimbursement and medical terminology.
• 2 years related experience; 1 year experience in case management or utilization review.
• Associate degree in business or healthcare field preferred.

USD $23.65 - USD $42.03 /Hr.