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.
* 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.
* 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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