Utilization Review Specialist

The Utilization Review Specialist works under the direction of the Utilization Management Manager and acts as an interdisciplinary team member within the Utilization Management Department. The Specialist is responsible for providing verification of benefits, authorization procurement and other assigned tasks, and for collaborating with the UM RN and members of the interdisciplinary team—such as Physicians, Case Managers, Social Workers—and interdependent departments—such as Patient Access and Billing—to avoid unnecessary delays in patient care, discharge, or billing.

The Specialist serves as the first point of escalation for payors requiring assistance in gaining additional or missing information to support authorization and ensures procurement of authorization upon admission, discharge, and accuracy of authorization information. The Specialist also timely escalates barriers to authorization requiring clinical expertise and assists in coordination of Peer to Peer discussions with the payor. This position does not directly supervise any other caregivers.

• Acts as interdisciplinary team member within the Utilization Management (UM) department.
• Accurately completes assigned (triaged by UMS) requests submitted from payors; promptly escalates cases requiring clinical expertise to UM RN and / or multidisciplinary team.
• Escalates Medical Necessity (patient status / LOC) concerns and other UM concerns to the Physician Advisor.
• Submits clinical reviews to payors. Submits clinical information supporting admission, continued stay reviews, and provides discharge information to payors upon request.
• Identifies and escalates all 1MN Medicare and 2MN Obs stays for review at committee through use of assigned work queues.
• Reviews and addresses all discharged encounters pending payor authorization follow-up (i.e. additional authorized days, authorization accuracy).
• Maintains a working knowledge of UM specific changes (i.e. changes in authorizations, payor contracts, CMS, and regulatory requirements).
• Prepares and facilitates the delivery of regulatory notices and ensures compliance with payor regulations.
• Supports clinical denials and appeals processes, both concurrent and post claim.
• Supports peer to peer workflows and the discharge appeal process.
• Collaborates with the Case Management and Social Work teams (i.e. extended observation stays, patients no longer meeting medical necessity, status changes).
• Communicates and collaborates with Patient Access, Patient Financial Services (PFS) and Health Information Management (HIM).
• Provides timely and continual coverage of assigned work area to ensure all accounts are complete.
• Documents all interactions with patient, family / caregiver, and patient’s care team.
• Complies with all documentation requirements.
• Follows up on action items prior to the end of shift and completes all tasks within department guidelines.
• Adheres to the policies, procedures, rules, regulations, and laws of the hospital and federal and state governing bodies.
• Assists Department Manager with quality audits.
• Participates in tracking of departmental quality measures by abstracting and reporting UM data.
• Supports the vision, mission and values of the organization in all respects.
• Supports Value Improvement Practice (VIP
  - Lean) principles of continuous improvement with energy and enthusiasm, functioning as a champion of change.
• Provides and maintains a safe environment for caregivers, patients and guests.
• Conducts all activities with the highest standards of professionalism and confidentiality. Complies with all applicable laws, regulations, policies and procedures, supporting the organization’s corporate integrity efforts by acting in an ethical and appropriate manner, reporting known or suspected violations of applicable rules, and cooperating fully with all organizational investigations and proceedings.
• Delivers customer service and/or patient care in a manner that promotes goodwill, is timely, efficient and accurate.
• May perform additional duties of similar complexity within the organization, as required or assigned.

• Required
  :
  Associate degree or higher in Health Information Management.
• Preferred
  : N/A

• Required
  :
  Current RHIT
• Preferred
  : N/A

• Required
  : 1 year experience in similar hospital related position in Health Information Management
• Preferred
  : N/A