Utilization Management Specialist: Salary, 40hrs/week - DAYS

About the position

Under direction of the Manager of Utilization Management, the Utilization Management Specialist is responsible for the coordination, processing and tracking of all potential utilization concerns from the third party payors for Albany Medical Center; and to do other related work as required. This individual will act as a liaison with all payors and review agents, providing required acuity information regarding patients and issuing notice of non-coverage as appropriate. This position is also responsible for the processing of adverse determinations received from third party payors, coordinating with Patient Financials Services, Admitting/Access Operations, attending physicians, Medical Director and AMC Case Managers and R1 Physician advisory services.

Responsibilities

• Contributes to the creation of a compassionate and caring environment for patients, families and colleagues through displays of kindness and active listening.
• Recognizes and appreciates that each employee's work is valuable and contributes to the success of the Mission.
• Demonstrates excellence in daily work and actively participates in performance and quality improvement activities.
• Exhibits positive service excellence skills to patients, visitors and coworkers.
• Demonstrates effective teamwork by interacting in a positive manner with colleagues.
• Initiates open communication, conveys positive intent, and offers assistance.
• Contributes to a safe and secure environment for patients, visitors, and colleagues.
• Demonstrates stewardship by thoughtful and responsible use of resources.
• Supports the Manager in planning, organizing, directing of the Utilization Management services.
• Participates in the development of departmental goals and develops plans to achieve those goals.
• Acts as contact person for payors regarding utilization issues.
• Coordinates appeal of adverse determination with relevant parties.
• Maintains all correspondence and provides follow up with third party payors.
• Demonstrates in-depth knowledge of utilization criteria for Medicare, Medicaid, and private insurers.
• Delegates and coordinates the work of Utilization Review ASA support staff.
• Tracks denials and develops action plans to decrease bad debt.
• Maintains database of utilization issues and identifies trends in payor activity.
• Completes end of month reports.
• Demonstrates proper use of MCG and documentation requirements.
• Models AMC cares standards and demonstrates willingness to participate in hospital wide initiatives.
• Assists in the development of policies and procedures, standards of care and practice.

Requirements

• Knowledge of utilization criteria for Medicare, Medicaid, and private insurers.
• Ability to analyze data and identify trends.
• Strong communication skills for liaising with payors and medical staff.
• Experience in a healthcare setting, particularly in utilization management.

Nice-to-haves

• Experience with MCG and documentation requirements.
• Familiarity with CMS and payor regulations.

Benefits

• Excellent health care coverage with lower copays at most Albany Med providers.
• A wide array of services and programs to support emotional, physical, and mental wellbeing.