Utilization Management Specialist II

Under general supervision, provides utilization review and denials management for an assigned patient case load. This role utilizes nationally recognized care guidelines/criteria to assess the patient’s need for outpatient or inpatient care as well as the appropriate level of care. The role requires interfacing with the case managers, medical team, other hospital staff, physician advisors and payers.

Responsibilities and Tasks

• Performs timely and accurate utilization review for all patient populations, using nationally recognized care guidelines/criteria relevant to the payer.
• Communicates with case manager, physician advisor, medical team and payors as needed regarding reviews and pended/denied days and interventions.
•  Supports concurrent appeals process through proactive identification of pended/denied days. Implements the concurrent appeals process with appropriate referrals and documentation.
• Ensures appropriate Level of Care and patient status for each patient (Observation, Extended Recovery, Administrative, Inpatient, Critical Care, Intermediate Care, and Med-Surg)
• Reviews tests, procedures and consultations for appropriate utilization of resources in a timely manner
• HINN discussions/Observation Education
• Assists Case Manager in Avoidable Days Collection
• Ownership of Regulatory Compliance related to Utilization Management conditions of participation
• Assures appropriate reimbursement and stewardship of organizational and patient resources.
• Actively reports opportunities to improve reimbursement and responds to relevant data
• Collaborates with admitting specialists regarding authorization policies and procedures of third party payers.
• Remains current on clinical practice and protocols impacting clinical reimbursement
•  Participates in department improvement initiatives
• Serves to orient and educate Utilization Manager 1s
• Provides oversight and education to utilization management interns placed in the practice area

Education and Experience 

• Licensure as a Registered Nurse or other equivalent health care license in the state of Maryland, or eligible to practice due to Compact state agreements outlined through the MD Board of Nursing, is required 
• Minimum of 12 months experience in case management or utilization management required

 Knowledge, Skills and Abilities

• Knowledge of utilization management is required. 
• Highly effective verbal and written skills are required.
• Strong communication skills, self-confidence and experience in working with physicians are required. 
• Excellent analytical and team building skills, as well as the ability to prioritize and work independently are required. 
• The ability to work collaboratively with other disciplines is required.
• Ability to work with Hospital/ Utilization Management and related software programs is required.

Patient Safety

Ensures patient safety in the performance of job functions and through participation in hospital, department or unit patient safety initiatives.

• Takes action to correct observed risks to patient safety.
• Reports adverse events and near misses to appropriate management authority.
• Identifies possible risks in processes, procedures, devices and communicates the same to those in charge.