Utilization ManagementCDI Specialist
Utilization ManagementCDI Specialist
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Job Description
Responsible for applying clinical and benefits administration policy guidelines to requests for authorizations.
Provides accurate prompt and appropriate medical authorizations to requests for Patients Insurance Companies and Providers.
Ensures that clinical documentation complies with federal laws.
Demonstrates the mission of HRMC by displaying REACH our core value system:
- Respectful We value the unique talents ideas contributions and circumstances of each individual.
- Engaged We value being active positive participants at work and in our communities.
- Available We value providing local access to care for our communities while being present for each other.
- Competent We value knowledgeable peoplecentered innovative and technology driven teams.
- Helpful We value always helping others with kindness and compassion.
Essential Job Functions:
Demonstrates understanding that patients physicians visitors and other hospital staff are customers and consistently seeks to exceed customers expectations.
Uses established criteria to conduct preliminary decision review for services requiring prior authorization
Applies clinical and benefit administration policy guidelines to requests for authorizations
Assesses the need for additional information to complete a service decision request
Enters authorizations into the EMR data system to ensure timely review of and downstream claims processing
Works closely with Care Coordinator and Medical staff to escalate decisions that require clinical review and oversight
Communicates results of reviews in the EMR UR space for the primary care team and clinical reviewers
Handles all authorization requests timely and accurately adhering to performance measures
Follows department and organizational policies and procedures as well as adheres to all applicable regulatory contractual and compliance requirements
Fulfills duties as above within service standard turnaround times
Analyzes medical information and trains staff in medical documentation practices
Facilitates the Utilization Management Program Committee and Plan
Other Job Duties:
Promotes and maintains confidentiality of information regarding patients families health care personnel and the facility.
Participates in hospitals quality risk and utilization plan.
Qualifications: (Minimum Education and Experience)
Associates degree or equivalent experience bachelors degree (preferred)
2 years professional work experience in health care managed care or insurance
Education training or experience as a medical coder medical billing Insurance Coordinator or other relevant clinical background highly preferred
Knowledge Skills and Abilities:
Familiarity with utilization management review preferred
Knowledge of CPT and ICD coding highly preferred
Flexibility and understanding of individualized care plans
Excellent interpersonal verbal and written communication skills
Ability to work independently and make decisions
Work in a teambased environment
Working knowledge of and ability to navigate through the healthcare system (insurances Medicare Medicaid physician office operations)
Required Experience:
Unclear Seniority
Employment Type
Full-Time
