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Utilization Management Specialist-Admissions


Company

Lancaster General Hospital

Cost Center

2024 Utilization Mgmt-Admit/Denial

Supervisory Organization

Utilization Management

Grade

G15

Summary

HOURS:  Fulltime, dayshift.  Every 6th weekend rotation.

POSITION SUMMARY: The Utilization Management Specialist - Admissions is responsible for evaluating medical records to determine severity of patient's illness and the appropriate patient class in accordance with industry guidelines. Serves as a liaison for patients and hospital with insurance companies.

ESSENTIAL FUNCTIONS: Qualified individuals must have the ability (with or without reasonable accommodation) to perform the following duties:

  • Complete chart review and communicate patient status/medical needs with insurance companies in order to advocate for patients and facilitate appropriate reimbursement while meeting tight payor deadlines, often less than 24 hours.
  • Amend patient status and complete order requests to Attending Physician/Advance Practice Provider urgently.
  • Deep and thorough knowledge of clinical process in the Acute Care setting with the ability to make bold, independent decisions in regard to patient status and authorization requests.
  • Ensure that patients are assigned the appropriate patient class throughout patient stay by using Industry standard review tools, department policies, and critical thinking.
  • Frequently coordinate with clinical staff to facilitate appropriate documentation to support patient class, optimal patient outcomes, and minimize denied days.
  • Work closely with physician advisers to provide timely, accurate and thorough clinical reviews to assist in patient class decision-making process.
  • Ability to handle an unpredictable workload shaped by census and payor demands.  Must be able to complete assignment by end of day to comply with department standards and payor requests.
  • Complete all documentation, including authorizations and denials according to departmental standard operating procedures.
  • Communicate with Patient Financial Services staff regarding changes to patient class to ensure proper billing.  Work with Financial Clearance and Registration staff to ensure proper billing.
  • Facilitate Peer to Peer appeal processes post-denial in a timely fashion.
  • Follow up with payers to account for all bed days for authorization prior to discharge.
  • Maintain knowledge of specific payer requirements to ensure efficient review process.
  • Serve as a point of contact/subject matter expert in the process of outside facilities transferring patients to Lancaster General Hospital.

JOB REQUIREMENTS

MINIMUM REQUIRED QUALIFICATIONS:

  • Current licensure as a Registered Nurse, issued by the Pennsylvania Board of Nursing
  • Bachelor’s of Science in Nursing, Life Sciences, or Healthcare related fields
  • Minimum of five years of nursing experience which includes a minimum of three years in an acute care hospital setting
  • Excellent written, interpersonal communication and negotiation skills. Strong critical thinking skills and the ability to perform clinical/chart review efficiently. Strong analytical, data management and computer skills. Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components. Ability to advocate for the patient, as well as the hospital’s best interests.
  • Ability to adjust/adapt to varying needs of the department and the ever changing industry requirements
  • Ability to work independently and exercise sound judgment in interactions with the health care team
  • Ability to tolerate high volume production standards.

PREFERRED QUALIFICATIONS:

  • Knowledge of health care and managed care delivery systems. This includes standards of medical practice; insurance benefit structures and related legal/medical issues.
  • Knowledge of utilization management and quality improvement processes. 
  • Experience working within the managed care environment.

LGH Full Time Posted on 06/29/2020