Utilization Management Specialist

Description

All the benefits and perks you need for you and your family:

• Benefits and Paid Days Off from Day One

• Student Loan Repayment Program

• Career Development

• Debt-free Education* (Certifications and Degrees without out-of-pocket tuition expense)

Our promise to you:

Joining AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.

Schedule: Full-Time

Shift: Days

The community you’ll be caring for: 301 MEMORIAL MEDICAL PKWY, Daytona Beach, FL 32117 (100% REMOTE POSITION)

The role you’ll contribute: The Utilization Management (UM) Specialist works under the direction of the Utilization Management Manager and supports the Utilization Management team with Emergency, Observation and Inpatient visits. The UM Specialist is responsible for providing clerical assistance to the Utilization Management Nurses (UM RN) to assist with verification of benefits, authorization procurement and other assigned tasks as needed. The UM Specialist is responsible for collaborating with the UM RN and other members of the interdisciplinary team (i.e. Physicians, Care Managers, Social Workers, etc.) or interdependent departments (i.e. Patient Access, Billing, etc.) to ensure unnecessary delays in patient care, discharge or billing.

The UM Specialist will serve as the first point of escalation for payors requiring assistance in gaining additional or missing information to support authorization. The UM Specialist will be responsible for ensuring procurement of authorization upon admission and discharge as well as, accuracy of authorization information. The UM Specialist will ensure timely escalation of barriers to authorization requiring clinical expertise and assist in coordination of Peer-to-Peer discussions with the payor.

The value you’ll bring to the team

• Coordinates and supports clerical and administrative activities of the Utilization Management team

• Collaborates and communicates with payor via phone, fax or payor portal

• Tracks and monitors requests through EMR

• Ensures incoming requests are responded to promptly and accurately

• Obtains and enters authorization numbers from payors

• Verifies up-to-date concurrent authorizations for in-house patients

• Reviews and monitors accounts to ensure proper documentation of benefits and authorizations have been completed in required fields and notes

• Supports concurrent denials process

• Assists in coordinating Peer-to-Peer discussions with the payor for Physician Advisors, Attending Physicians and UM RNs

• Updates patient demographic/patient type/coverage, as needed

• Assists UM Coordinator in managing central fax (Vyne)/email accounts (Central Repository), as needed

• Communicates with all members of the Interdisciplinary Team (i.e., nurses, physicians, etc.), as needed

• Assists department leadership with quality audits as needed

• Timely escalates cases requiring clinical expertise to UM RNs

• Interacts with physicians, physician office personnel, and/or care management departments on an to assure resolution of issues, as needed

• Provides timely and continual coverage of assigned work area in order to ensure all accounts are completes

• Monitors daily discharge reports to assure all patient stay days are authorized

• Maintains a working knowledge of payor contracts and regulatory requirements

• Adheres to the policies, procedures, rules, regulations, and laws of the hospital and federal and state regulatory bodies

• Communicates and collaborates with Patient Financial Services (PFS) and Health Information Management (HIM) to render appropriate information needed to secure reimbursement, as needed

• Collaborates with Care Management team to ensure payor compliance regulations (i.e. Condition Code 44)

• Adheres to HIPAA regulations by verifying pertinent information to determine caller authorization level before releasing account information.

• Completes any other tasks within department guidelines.

Qualifications

The expertise and experiences you’ll need to succeed:

• Knowledge of Care Management processes / workflows

• High School diploma or GED

• Two (2) years’ experience in Patient Access, Revenue Cycle Operations, Pre-Access, or related department.

• Associate degree and/or higher-level education, or completed coursework, in Health Services Administration or other related medical or business field

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.