Utilization Management Specialist

Department: Utilization Management
Schedule: Full-time
Shift: Days/PMs and Wknds
Salary: $20.06Job Details:
The Utilization Management Specialist (Nurse or Health Information Technician) performs medical necessity review of initial patient placement and continued stay review by applying criteria during review of medical records. Communicates initial review determinations to the attending physician and external review organizations as required by the patients insurance coverage or by contract. Collaborates with the health care team to assure that patient needs and discharge plans are documented and certified as medically necessary and appropriate. Occassionally performs case management services, including coordination of care between health care providers, assisting patients to identify personal health care goals, monitoring progress and outcomes towards goals, assists with management of health care benefits and assists the patient in obtaining necessary services. Participates in performance improvement activities to achieve and sustain safe and high quality patient care services and assure compliance with regulations and contracts. Educates physicians, nurses, ancillary staff and patients through formal and informal means. Works as part of a team to review patient care and provide level of care consultation to the medical staff 7 days per week and 24 hours per day.Education/Learning Experience:
Required: Associate or Bachelor Degree in Health Information Management OR ADN or BSN in Nursing.Work Experience:
Required: 2 years of progressively responsible health care experience, i.e. hospital, health plan or closely related organization OR 2 years of progressively responsible nursing service in a hospital setting.
Desired: Previous utilization review, quality improvement or case management experience.Skills/Knowledge:
Required: 1. Teamwork as demonstrated by the ability to build effective relationships and compliment the roles of others.
2. Communication as demonstrated by clear written and verbal communication of facts, ideas, and thoughts and the ability to listen effectively to the input and feedback of others.
3. Adaptability as demonstrated by the ability to adjust quickly and positively to changing work priorities and conditions.
4. Analytical reasoning as demonstrated by the ability to identify problems, secure relevant information and determine potential solutions. Must have the ability to interpret complex data from multiple sources and propose solutions or next steps.
5. Decisiveness as demonstrated by the ability to make informed decisions and follow through with purposeful action.
6. Competent use of Microsoft word processing and spread sheet applications.
Desired: Knowledge of utilization review principles, medical necessity and leve of care criteria, managed care principles, case management models and approaches, reimbursement systems and diagnostic and operative coding (ICD and CPT). Licenses/Certifications:
Required: Current AHIMA certification as RHIT or RHIA OR Current Wisconsin RN license (if licensed in another state, will obtain Wisconsin RN license within 6 weeks of hire).
REQUIREMENTS
Please see Job Description