Utilization Management Specialist, Psych Services

Full time Day shift role

The University of Maryland Medical System (UMMS) is an academic private health system, focused on delivering compassionate, high quality care and putting discovery and innovation into practice at the bedside. Partnering with the University of Maryland School of Medicine, University of Maryland School of Nursing and University of Maryland, Baltimore who educate the state's future health care professionals, UMMS is an integrated network of care, delivering 25 percent of all hospital care in urban, suburban and rural communities across the state of Maryland. UMMS puts academic medicine within reach through primary and specialty care delivered at 11 hospitals, including the flagship University of Maryland Medical Center, the System's anchor institution in downtown Baltimore, as well as through a network of University of Maryland Urgent Care centers and more than 150 other locations in 13 counties. For more information, visit www.umms.org.

This position is located within the Psychiatric Admissions and Referral Center (PARC). PARC is the administrative hub for referrals to inpatient and partial hospitalization/intensive outpatient psychiatry programs at University of Maryland Medical Center and University of Maryland Medical Center Midtown Campus. This work also includes ensuring insurance initial authorization for these levels of care. 

1. General Summary
    

Under general supervision, provides utilization review and denials prevention for assigned cases. Utilizes care guidelines and criteria to assess the patient’s need for outpatient or inpatient care and the appropriate level of care.  Interfaces with third party payors, team members, social workers/case managers, review utilization management specialists, physicians/providers/medical teams, patient access team members, and other hospital staff.

1. 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.

1. 1. Performs timely and accurate utilization review for all psychiatry patient populations, using nationally recognized care guidelines/criteria relevant to the payor.
   2. Communicates with patient access, utilization management specialists responsible for concurrent reviews, social workers/case managers, physicians/medical teams, and payors as needed regarding reviews and pended/denied days.
   3. In conjunction with Utilization Management, supports concurrent appeals process through proactive identification of pended/denied days.   Implements the concurrent appeals process with appropriate referrals and documentation.
   4. Performs ongoing monitoring of initial authorization completion for all patients processed by PARC. This may include:
      1. 1. Manages authorization work queues.
         2. Follows up on pending authorizations (initiated by internal and external sources) to ensure completion and approval, including documentation in all necessary workflows.
         3. Investigates and works through to completion insurance eligibility/benefits/authorization cases which are complex or require longer than standard timeframe to complete (e.g. unclear coverage, coverage change or newly identified during admission, readmit to psychiatry after medical procedures which require formal discharge).
         4. May assume primary responsibility for authorization efforts during periods of high volume to ensure authorizations are complete.
         5. Collaboration with utilization management team responsible for concurrent reviews.
   5. Ensures appropriate Level of Care and patient status for each patient
   6. Reviews tests, procedures, and consultations for appropriate utilization of resources in a timely manner
   7. Assures appropriate reimbursement and stewardship of organizational and patient resources.
   8. Actively reports opportunities to improve reimbursement and responds to relevant data
   9. Collaborates with admitting specialists regarding authorization policies and procedures of third-party payors.
   10. Remains current on clinical practice and protocols impacting clinical reimbursement. Provides training and guidance to other PARC team members on same.
   11. Leads authorization-focused quality improvement initiatives and special projects

Education and Experience 

1. Bachelor’s degree in psychology, social work, nursing, or a related health and human services field is required.
2. One (1) year previous experience in behavioral health prior authorizations and verification of eligibility/benefits is required.
3. One (1) year previous experience in inpatient and partial hospitalization/intensive outpatient levels of care is strongly preferred. Minimum experience of 2 years is preferred.   

          Knowledge, Skills and Abilities

1. Knowledge of utilization management is preferred. 
2. Highly effective verbal and written skills are required.
3. Strong communication skills, self-confidence, and experience in working with physicians are required. 
4. Excellent analytical and team building skills, as well as the ability to prioritize and work independently are required. 
5. The ability to work collaboratively with other disciplines is required.
6. Effectively manage competing priorities with high reliability and attention to detail.
7. Proficient in the use of technology to support communication, review of records, and documentation. Requires daily use of telephone, fax, email, secure text messaging, internet navigation including third party online portals, Microsoft Office applications, and electronic medical records system (Epic).  
8. Familiarity with psychiatric illnesses including working knowledge of DSM/ICD diagnostic categories and disorders and psychotropic medications commonly used in treatment of psychiatric illnesses and substance use disorders is required.

All your information will be kept confidential according to EEO guidelines.

Compensation:

Pay Range: $31.78-$44.50

Other Compensation (if applicable):

Review the 2024-2025 UMMS Benefits Guide