Utilization Specialist

The information described in this job description has been designed to indicate the general nature of the work performed. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities and qualifications required of employees assigned to this job.

Other information:

Job Summary

Reviews chart documentation to justify patient care in order to meet agency reimbursement requirements, justify admission, treatment and length of stay. Works effectively and cooperatively within the workplace. Location/Department specific tasks and competencies may apply.




Essential Functions

Coordinate and track utilization management authorizations from third-party payers, including pre-certification, concurrent and retrospective authorizations for the Case Management team. Coordinate and facilitate medical record information required for authorizations and appeals management for Medicare/Medicaid/Commercial payers. Utilize communication, organizational, and problem solving skills to implement the plans and interventions defined by the RN Case Managers and Social Workers. Promote and evaluates the effective utilization of resources using current knowledge, awareness of community services, and assuming a pivotal role with the patient care team to achieve optimal clinical and resource outcomes around post acute care transitions. Obtain Medical Assistance authorizations and conducts financial chart auditing to further define resources available for post-acute care facilitation. Maintain ability to effectively utilize Microsoft Office (Outlook) and department specific software applications to perform work. Communicate effectively and cooperatively in the workplace. Actively contribute to the achievement of Quality Improvement and Lean Process Improvement activities. Complete all mandatory learning requirements in a timely manner. Maintain current licensure and/or certification as required. Attend and actively participate in all department, team and/or committee meetings. Comply with all Skagit Regional Health, department and location specific policies and procedures. Perform other duties as assigned by Supervisor or designee.




Education

High School diploma or GED required.




Experience/Training

Minimum one (1) year current related utilization management experience preferred.




License/Certifications

None required.




Other Skills

Effective verbal, written and interpersonal communication skills required. Must be able to effectively utilize Microsoft Office applications to perform work. Well developed problem solving and analytical skills required. Must be able to effectively prioritize workload amongst frequent interruptions with competing priorities. Knowledge of utilization management and pre-authorization. Ability to coordinate work schedule with requirements of position (may include overtime and weekend work).




Physical Demands and Work Environment

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to sit for long periods of time; when working in office. Repetitive tasks such as typing, sitting, answering phones, and interacting with computers and computer systems most of the day is a function of the position. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to focus. This position requires working in an indoor, environmentally controlled environment when in the office.