Utilization Management Specialist, Full-Time

Job Summary:
Initiates, manages, supervises and performs a wide range of functions that are essential to meet departmental goals and expectations. Position initiates and manages processes that include creating, tracking, and analyzing data for positive and negative trends, and participates in discussions with department leadership making recommendations on process changes and/or revisions in data collection and/or methods to improve department and hospital utilization functions. This position also manages and supervises the on-boarding of new department personal, manages departmental Kronos, FMLA, license verification, employee files, setting up interviews, staff meetings and conferences, including meeting minutes, managing all departmental records and more. Position also assists the Utilization Management Analytics Engineer with managing processes and collection of data for the Corporate Director of Utilization Management for use in presentations to various system-wide hospital committees including the hospital's medical staff and the Board of Directors. Additional responsibilities include scheduling and organizing the quarterly UR Committee meeting for all Erlanger system-wide facilities including Erlanger's acute care facilities and also our critical access facilities at Erlanger Bledsoe and Erlanger Western Carolina to meet requirements by CMS and DVN including preparing hand-outs and assisting the Corporate Director of Utilization Management with any other preparation needed for additional agenda items. Position will be involved in the expansion of current projects such as managing the member appeal process, self-denial determination process and the pre-op surgical assessment process. Position is also responsible for managing and tracking invoices, ordering department office supplies, verifying all department computers and connections are working as needed to support department staff to be able to work in a remote or onsite environment.

Position will be responsible for supervising the UR Member Appeals and Project Coordinator to enter and track member appeals, manage and prepare Crystal reports for LLOS (long length of stay) meetings for discussion and review with Case Management and Utilization leaders and physician advisors process and send Medicare self-denial determination letters to both physicians and patients and also enter and track usage of pre-op surgery assessments and related patient outcomes.

Additional responsibilities include administrative, data entry and analysis, managerial and staff support functions including organizing and managing department records, files, contracts (Meditract), data analysis, meeting agendas including handouts and presentation material, communication records with insurance companies, invoices, expenditure tracking, check requests, TRACE tracking and archiving, educational material for staff, personal files, MOON form mailing and tracking, and more. Position also is responsible for customer service assistance, respond to, customer questions and issues, and being able to multi-task and prioritize several tasks and requests while managing time efficiently. Must have superior customer service skills including being able to de-escalate difficult situations. Employee must be able to work independently with minimal supervision. Support responsibilities may also include assisting with patient admission notifications to insurance companies, assisting with discharge notifications and investigating bill holds by accessing insurance websites to check for approvals and denials to share and coordinate with RN staff to minimize length of time of account bill holds.

Employee will have excellent communication skills, both verbal and written, and be able to create, develop, update and organize spreadsheets and other communication tools to include documentation formats to be utilized in organizing department records for a consistent archival format. Employee must have education or experience with medical terminology and/or experience either with a clinical assistant type position or previous work in a medical facility, physician practice office or insurance company.

Education:
Required:
Associates degree in business or a medical related field, OR high school graduate with certification as a Certified Clinical Medical Assistant or other medical certification and at least five years post high school education or related work experience in a general office practice, medical facility, insurance company, or business communication environment.

Preferred:
Bachelor's degree in business or health care administration or comparable education and experience.

Experience:
Required:
Five years of clinical support service or secretarial experience in the health care setting. Must be proficient in Microsoft Office Programs including Word, Excel, Power Point, etc., Adobe, Zip files and be able to teach others basic knowledge of the same programs. Must have knowledge of how to trouble-shoot basic computer hardware issues to assist department staff as needed. Must have knowledge or ability to learn Erlanger frequently used programs such as Kronos, AP Check Requests, ZOOM, etc.

Position Requirement(s): License/Certification/Registration
Required:
N/A

Preferred:
N/A

Department Position Summary:
Performs a wide range of business office functions for the Utilization Management team within Erlanger. Knowledge of medical terminology required. Microsoft office and Excel computer skills required. Position will be in general office environment and may require travel between campuses. Adaptability to constantly changing work environment required; frequent interruptions; flexible hours. Must be able to sit at a desk for extended periods of time.