UTIL MGMT SPECIALIST I

Overview

Utilization Management Specialist, Revenue Integrity and Utilization

Full Time, 80 Hours Per Pay Period, Day Shift

Covenant Health Overview:

Covenant Health is the region’s top-performing healthcare network with 10 hospitals, outpatient and specialty services, and Covenant Medical Group, our area’s fastest-growing physician practice division. Headquartered in Knoxville, Covenant Health is a community-owned integrated healthcare delivery system and the area’s largest employer. Our more than 11,000 employees, volunteers, and 1,500 affiliated physicians are dedicated to improving the quality of life for the more than two million patients and families we serve every year. Covenant Health is the only healthcare system in East Tennessee to be named a Forbes “Best Employer” seven times. 

Position Summary:

The Utilization Management Specialist I will perform utilization management functions to include medical necessity reviews to promote a utilization management program. The UM Specialist prepares and reviews necessary documentation for insurance utilization management processes and coordinates communication between members of the UM team to ensure timely follow through for status placement.  The UM Specialist collaborates with attending physician if ambiguous documentation pertaining to patient status placement requires clarification. The UM Specialist utilizes electronic utilization management database for documentation of interventions and communications so as to ensure accurate reporting.  Collaborates with patient account services, physicians, care coordinators, physician advisors and facility departments as related to utilization management. Communicates with hospital and payor medical directors in order to correctly determine the medical necessity of patient status with a patient advocacy focus.

Recruiter: Kathleen Rice || kkarnes@covhlth.com || 865-374-5386

Responsibilities

• Reviews providers’ requests for services and coordinates utilization management review.
• Reviews precertification requests for medical necessity for all payors as applicable, referring to the second level physician reviewer those that require additional expertise.
• Maintains accurate records of all communications and interventions related to utilization management.
• Sets up communications with payors and/or physicians as applicable.
• Collaborates with payor utilization management liaisons and medical directors as applicable.
• Reviews all cases received from the registration department to verify that the insurance pre-certification process has been completed in order to meet contractual obligations.
• Coordinates execution of notices (denials) of non-coverage when appropriate and communicates with key stakeholders to ensure that patient liability is correctly managed.
• Intervenes in Peer-to-Peer meetings between physicians and payors as applicable.
• Exhibits effective verbal and written communication skills in order to clearly present clinical and financial data to various audiences as necessary.
• Completes daily work lists for utilization review meeting the time frames set forth by Covenant Health.
• Performs medical necessity screening of clinical information for all payors. 
• Develops and maintains a professional rapport with physicians and physician office staff.
• Performs daily chart reviews for observation hour calculations and observation charge entry in STAR.
• Performs delayed claims to determine appropriate number of Observation Hours as applicable. Adjusts charges for Observation Hours in STAR as applicable.
• Assist with all insurance requested audits and provides information to supervisor related to inaccurate and/or missing documentation as applicable.
• Uses effective relationship management, coordination of services, resource management, education, patient advocacy and related interventions to:
• Promote patient advocacy
• Promote quality of care
• Promote cost effective medical outcomes
• Promote appropriate admission status
• Provide continuity of care between utilization management and care coordinators
• Commits to professional development towards becoming an expert in utilization management including but not limited to:
• Knowing Medicare rules and regulations related to utilization
• Knowing payor policies related to utilization management
• Knowing Covenant Health’s Policies related to utilization management.
• Keeping abreast of current changes affecting utilization management as applicable.
• Assists with delayed claims review to determine appropriate number of observation hours as applicable.
• Attends meetings as required and participates on committees as directed.
• Perform other related duties as assigned or requested.
• Supports, models and adheres to desired behaviors of the KBOS Constitution for caring which are; build a trusting environment by listening with an open mind and valuing different opinions; asking questions for understanding and allowing others to speak openly, do not gossip or criticize people behind their back, resolve conflicts, notice and express appreciation for good work and respect differences by listening with an open mind.
• Supports, models and adheres to the desired behaviors of the KBOS Constitution and Covenant Health for  service which are; take ownership for our mistakes, resolve customer problems on the spot whenever possible, treat all people with respect and kindness, strive to meet or exceed customer expectations, collect   and use customer feedback/data to improve processes and service and set an example for accountability and responsiveness: return e-mail and phone calls promptly, assure deadlines are met, keep commitments.

Qualifications

Minimum Education:          

None specified; will accept any combination of formal education and/or prior work experience sufficient to demonstrate possession of the knowledge, skill and ability needed to perform the essential tasks of the job, typically such as would be equivalent to a high school diploma or GED.  Preference may be given to individuals possessing a HS diploma or GED.

Minimum Experience:         

At least two (2) years of utilization management, case management or equivalent experience.

Licensure Requirements:    

Current Tennessee LPN license is preferred