Utilization Management Specialist - Rehab Admissions - Days

General Summary

Performs a variety of duties related to pre-certification requirements for Medicare, Medical Assistance and third-party payers. Ensures timely notification and communication of pertinent clinical data to support admission, clinical condition, and continued stay. Assists with data collection, analysis and reporting.

Shift

Full Time, 8:00-4:30p

Duties and Responsibilities

Essential Functions:

• Reviews assigned cases for preauthorization and coordinates authorization and certification.
• Performs concurrent review of cases to obtain continued stay authorization.
• Provides notification of discharge date and discharge destination to payer.
• Works closely with and prepares information for outside review agencies.
• Assists with the collection and analysis of utilization patterns and denied cases.
• Supports the Utilization Management Nurse with case research and analysis.
• Works with medical and professional staff on a case-by-case basis to obtain appropriate clinical documentation for review as well as coding activities and DRG assignments.
• Liaisons between third party payors, physician advisor team and the care team regarding questions related to authorization status and/or contractual guidelines.
• Refers third party payer denials and downgrades to the physician advisor team and follow through with the recommendations.
• Provides feedback to payer contracting regarding payer actions that cause barriers to the utilization review process.
• Maintains up to date tip sheet on assigned payer/payers utilization review process.

Common Expectations:

• Maintains established policies and procedures, objectives, quality assessment and safety standards.
• Participates in educational programs and inservice meetings.
• Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation.

Qualifications

Minimum Education:

• High School Diploma or GED Required
• Associates Degree Preferred

Work Experience:

• 2 years Utilization Management. Required

Knowledge, Skills, and Abilities:

• Basic computer skills.

Benefits Offered:

• Comprehensive health benefits
• Flexible spending and health savings accounts
• Retirement savings plan
• Paid time off (PTO)
• Short-term disability
• Education assistance
• Financial education and support, including DailyPay
• Wellness and Wellbeing programs
• Caregiver support via Wellthy
• Childcare referral service via Wellthy