Utilization Management Specialist- Admissions REMOTE
full time day shift, no holidays, every 6th weekend, work from home after orientation
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.
SECONDARY FUNCTIONS: The following duties are considered secondary to the primary duties listed above:
- Participates in Continuous Improvement for the department and the organization.
- Identifies professional needs to maintain expertise and keep current with health care trends, both clinical and financial.
- Participates in orientation and education of individuals to the functions of this position.
- Participate in weekend coverage based on department rotation
- Other duties as assigned.
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.
- 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.
Attention/Concentration: The following level of ability is essential for the jobholder to focus on certain aspects of current experience and reject others.
- The position requires the ability to attend to more than one aspect of a situation simultaneously. It is highly likely that multiple task demands are going to be required of the individual at the same time.
- The position requires strong concentration skills. The individual must have the ability to voluntarily sustain concentration to a task over an extended period of time as a result of an effortful and usually deliberate heightened and focused state of attention.
New Learning and Memory: The following level of ability is essential for the jobholder to learn and retain material.
- The position requires that an individual be able to learn new tasks quickly and effectively. Job requirements change frequently. The ability to understand and carry out detailed, involved instructions is mandatory.
- A large portion of this position required reliance on verbal memory and new learning. Efficiency in processing of verbal information, either in written or spoken form, is a major requirement and prerequisite of the job. The individual must be able to attend to and process multiple bits of information simultaneously. The individual must be able to organize and categorize this information effectively so that later recall is feasible.
Problem Solving, Reasoning and Creative Thinking: The following level of ability that is essential for the jobholder to think (in order to solve a problem) by combining two or more elements from past experience or imaginative thought.
- The position required much autonomy of thought and problem solving. The individual must be able to apply principles of logical or scientific thinking to define problems. The individual must be able to think abstractly, which is manifested in the ability to form concepts, use categories, generalize from single instances, apply procedural rules and general principles, and be aware of subtle or intrinsic aspects of a problem. The development of hypothesis and potential solutions to problems involves careful interpretation, analysis and diagnosis. The individual must be able to collect data, establish facts, and draw valid conclusions. The individual must be able to think creatively with a degree of inventiveness, experimentation and intuition. They must be able to deal with a variety of concrete and abstract variables.
APTITUDES: The following are essential requirements of the position in relation to job-worker situations. These items describe how a worker must adapt, adjust, conform or act.
Performing under stressful conditions: Ability to perform under stress when confronted with emergency, critical, unusual, or dangerous situations, or in situations in which working speed and sustained attention are critical aspects of the job. Is subject to danger or risk, or to tension as a regular, consistent part of the job.
Communication: Ability to exchange information with others clearly and concisely; to present ideas, facts and technical information.
Interpersonal relations: Ability to maintain relationships that facilitate task accomplishment; to cooperate and resolve conflicts; to recognize needs and be sensitive of others.
EQUIPMENT USAGE REQUIREMENTS
Equipment/Tools: Computer, Phone, Copier, Printer, Fax, Office Supplies
Software: Microsoft Office Products, MIDAS, EPIC, RightFax, various web-based insurance portals.
Rarely 0-10%; Occasionally 11-35%; Frequently 36-70%; Continuously 71-100%
- Sit: Continuously 71-100%
- Stand: Rarely 0-10%
- Walk: Rarely 0-10%
- Bend: Rarely 0-10%
- Push: Rarely 0-10%
- Pull: Rarely 0-10%
- Kneel/Squat: Rarely 0-10%
- Reach: Rarely 0-10%
- Twist: Rarely 0-10%
- Balance: Rarely 0-10%
- Climb: Rarely 0-10%
Lifting: Degree of physical exertion is:
Light, exerting up to 10 pounds of force occasionally and/or a negligible amount of force frequently or constantly to move objects.
Sensory Abilities specifically required:
WORKING CONDITIONS: Exposure to hazardous conditions/ materials is negligible.
Disclaimer: This job description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills, efforts, or working conditions associated with the job. It is intended to be a reflection of those principal job elements essential for recruitment and selection, for making fair job evaluations, and for establishing performance standards. The percentages of time spent performing job duties are estimates, and should not be considered absolute. The incumbent shall perform all other functions and/or be cross-trained as shall be determined at the sole discretion of management, who has the right to amend, modify, or terminate this job in part or in whole. Incumbent must be able to perform all job functions safely.
PENN MEDICINE LANCASTER GENERAL HEALTH offers the following benefits to employees:
- 100% Tuition Assistance at The Pennsylvania College of Health Sciences
- Paid Time Off and Paid Holidays
- Shift, Weekend and On-Call Differentials
- Health, Dental and Vision Coverage
- Short-Term and Long-Term Disability
- Retirement Savings Account with Company Matching
- Child Care Subsidies
- Onsite Gym and Fitness Classes
Posted on 05/06/2022
PENN MEDICINE LANCASTER GENERAL HEALTH is an Equal Opportunity Employer, committed to hiring a diverse workforce. All openings will be filled based on qualifications without regard to race, color, sex, sexual orientation, gender identity, national origin, marital status, veteran status, disability, age, religion or any other classification protected by law.
Search Firm Representatives please read carefully: PENN MEDICINE LANCASTER GENERAL HEALTH is not seeking assistance or accepting unsolicited resumes from search firms for this employment opportunity. Regardless of past practice, all resumes submitted by search firms to any employee at PENN MEDICINE LANCASTER GENERAL HEALTH via-email, the Internet or directly to hiring managers at Penn Medicine Lancaster General Health in any form without a valid written search agreement in place for that position will be deemed the sole property of PENN MEDICINE LANCASTER GENERAL HEALTH, and no fee will be paid in the event the candidate is hired by PENN MEDICINE LANCASTER GENERAL HEALTH as a result of the referral or through other means.