Utilization Management Specialist
Posted on Aug 11, 2019 by The University of Maryland Medical System
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I. General Summary
Under general supervision, provides utilization review and denials management for an assigned patient case load. This role utilizes nationally recognized care guidelines/criteria to assess the patient s need for outpatient or inpatient care as well as the appropriate level of care. The role requires interfacing with the case managers, medical team, other hospital staff, physician advisors and payers.
II. Principal Responsibilities and Tasks
The following statements are intended to describe the general nature and level of work being performed by staff assigned to this classification. They are not to be construed as an exhaustive list of all job duties performed by personnel so classified.
- Performs timely and accurate utilization review for all patient populations, using nationally recognized care guidelines/criteria relevant to the payer.
- Communicates with case manager, physician advisor, medical team and payors as needed regarding reviews and pended/denied days and interventions.
- Supports concurrent appeals process through proactive identification of pended/denied days. Implements the concurrent appeals process with appropriate referrals and documentation.
- Ensures appropriate Level of Care and patient status for each patient (Observation, Extended Recovery, Administrative, Inpatient, Critical Care, Intermediate Care, and Med-Surg)
- Reviews tests, procedures and consultations for appropriate utilization of resources in a timely manner
- HINN discussions/Observation Education
- Assists Case Manager in Avoidable Days Collection
- Ownership of Regulatory Compliance related to Utilization Management conditions of participation
- Assures appropriate reimbursement and stewardship of organizational and patient resources.
- Actively reports opportunities to improve reimbursement and responds to relevant data
- Collaborates with admitting specialists regarding authorization policies and procedures of third party payers.
- Remains current on clinical practice and protocols impacting clinical reimbursement
- Bachelors in Nursing required. Licensure as a Registered Nurse in the state of Maryland, or eligible to practice due to Compact state agreements outlined through the MD Board of Nursing, is preferred.
- One year of experience in case management or utilization management with knowledge of payer mechanisms and utilization management is preferred. Two years experience in acute care and four years clinical healthcare experience preferred. Certified Professional Utilization Reviewer (CPUR) preferred. Additional experience in home health, ambulatory care, and/or occupational health is preferred.