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Utilization Mgmt Specialist at Valley Medical Center

Valley Medical Center
Full-time
On-site
Renton, WA, US
$94,894 - $142,341 USD yearly
šŸ“ Location: Renton, WA, US
šŸ’¼ Type: Fulltime
šŸ  Work: On-site
šŸ’° Salary: USD 94,894 - 142,341 (yearly)

šŸ“ Description: * ###### **Job Title:**


Utilization Mgmt Specialist
* ###### **Req:**


2025\\-0994
* ###### **Location:**


VMC Main Campus
* ###### **Department:**


Case Management
* ###### **Shift:**


Days
* ###### **Type:**


Full Time
* ###### **FTE:**


1
* ###### **Hours:**
* ###### **City State:**


Renton, WA
* ###### **Salary Range:**


Min $94,894 \\- Max $142,341/annual DOE








**Job Description:**


**Valley Medical Center**





**JOB DESCRIPTION**





The position description is a guide to the critical duties and essential functions of the job, not an all\\-inclusive list of responsibilities, qualifications, physical demands and work environment conditions. Position descriptions are reviewed and revised to meet the changing needs of the organization.





**TITLE:** Utilization Management Specialist





**JOB OVERVIEW:** Responsible to oversee the completion of utilization review duties in a timely manner and in accordance with the UM Plan and organizational priorities.





**DEPARTMENT:** Case Management





**WORK HOURS:** Monday \\- Friday as assigned, including a weekend and holiday rotation.





**REPORTS TO:** Director, Case Management





**PREREQUISITES:**



* Degree in Nursing required, BSN preferred.


* Unrestricted WA State RN License, required.


* Minimum three years of clinical experience in an acute care hospital setting.


* Previous Utilization Management experience preferred.


* Experience using UM compendia (MCG, InterQual) preferred.


* Computer literacy (MS Outlook, Word, Excel) required.


* Experience in use of electronic health record (EHR) preferred.


**QUALIFICATIONS:**



* General familiarity with the revenue cycle.


* General knowledge of third\\-party payer review and reimbursement systems and utilization monitoring requirements.


* Ability to set priorities, produce accurate work, and meet deadlines.


* Ability to function in a setting with a wide variety of duties and numerous interruptions.


* Effective communication skills, including group facilitation and conflict management skills.


* Ability to work in a collaborative team setting with peers.


* Interpersonal skills necessary to interact with the interdisciplinary teams of care providers, including physicians and nursing staff, to coordinate care for patients and families.


* Sensitivity to coordination of care requirements for all patients and families from a variety of ethnic, cultural, social, and economic backgrounds and with varied medical and developmental needs.


* Ability to communicate both verbally and in writing.


* Ability to type fluently and quickly, write legibly, spell correctly, and use accepted grammar.


**UNIQUE PHYSICAL/MENTAL DEMANDS, ENVIRONMENT AND WORKING CONDITIONS:**



See Generic Job Description for Administrative Partner.





**PERFORMANCE RESPONSIBILITIES:**



A. Generic Job Functions: *See Generic Job Description for Administrative Partner.*



B. Essential Responsibilities and Competencies:



* Review patients for appropriateness of admission, continued stay or readmission using compendia guidelines and criteria for determinations.


* Refer cases not meeting criteria to Physician Advisor per policies and procedures.


* Provide admission, concurrent and retrospective review information to external review and payer organizations in accordance with VMC's priorities and contracts.


* Anticipate patient's length of stay, treatment plans and outcomes based upon clinical knowledge, experience and length of stay guidelines.


* Work collaboratively with other disciplines including, but not limited to, physicians, staff nurses, case managers and social workers to facilitate appropriate resource utilization in the provision of safe patient care.


* Participate in discharge rounds/patient care conferences as indicated.


* Communicate with physicians regarding appropriateness of admission/readmission, continued stay and payment integrity issues.


* Refer quality, infection control and risk management issues to appropriate individual or department.


* Manage adverse determinations per policy and procedural guidelines including up to first level appeal when indicated.


* Complete non\\-governmental payer forms (patient status changes) for reimbursement.


* Deliver and counsel patient/family regarding Hospital Issued Notices of Non\\-coverage (HINN) letters when indicated.


* Deliver and counsel patient/family regarding Medicare Outpatient Observation Notices (MOO) notifications when indicated.


* Complete accurate, timely, and relevant documentation at all times.


* Function as preceptor in new departmental employee orientation.


* Collect data and report statistics as requested.


* Follow all VMC rules regarding HIPPA and confidentiality of records when performing duties of role.


* Perform other duties as assigned to support accurate and timely provision of utilization management services and patient account management.


* Demonstrate awareness of the importance of cost containment for the department.


Reviewed: 06/25



Grade: SEIU UM SPCLST



FLSA: NE



CC: 8715



**Job Qualifications:**


**PREREQUISITES:**



* Degree in Nursing required, BSN preferred.


* Unrestricted WA State RN License, required.


* Minimum three years of clinical experience in an acute care hospital setting.


* Previous Utilization Management experience preferred.


* Experience using UM compendia (MCG, InterQual) preferred.


* Computer literacy (MS Outlook, Word, Excel) required.


* Experience in use of electronic health record (EHR) preferred.


**QUALIFICATIONS:**



* General familiarity with the revenue cycle.


* General knowledge of third\\-party payer review and reimbursement systems and utilization monitoring requirements.


* Ability to set priorities, produce accurate work, and meet deadlines.


* Ability to function in a setting with a wide variety of duties and numerous interruptions.


* Effective communication skills, including group facilitation and conflict management skills.


* Ability to work in a collaborative team setting with peers.


* Interpersonal skills necessary to interact with the interdisciplinary teams of care providers, including physicians and nursing staff, to coordinate care for patients and families.


* Sensitivity to coordination of care requirements for all patients and families from a variety of ethnic, cultural, social, and economic backgrounds and with varied medical and developmental needs.


* Ability to communicate both verbally and in writing.


* Ability to type fluently and quickly, write legibly, spell correctly, and use accepted grammar.
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