Utilization Management Coordinator

WVU Medicine

About The Position

The Utilization Management Coordinator (UMC) specializes in assessing and mitigating concurrent denials to support authorization obtainment, avoid costly and lengthy appeals, and optimize reimbursement. The UMC has acute knowledge and skills in areas of utilization management (UM), medical necessity, patient status determination, payor behavior, and methods to overturn concurrent denials. The UMC partners closely with the Utilization Review Nurses, Physician Advisor team, and Clinical Appeals to develop and implement process improvement, prevent, and manage denials, and identify areas of education opportunity for physicians.

Requirements

Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC).
Four (4) years clinical experience in a hospital setting.
Three (3) years Utilization Review and/or Clinical Appeals and/or case management experience.
Effective verbal and written communication skills.
Strong interpersonal skills.
Strong attention to detail.
Knowledge of medical terminology required.
Knowledge of third party payers required.
Ability to use tact and diplomacy in dealing with others.
Working knowledge of computers.
Excellent customer service and telephone etiquette.

Nice To Haves

Bachelor’s Degree in Nursing OR Associate of Science in Nursing Degree (ASN) or Diploma.

Responsibilities

Assess all referred concurrent denials to determine appropriate next steps including, but not limited to, requesting peer to peer, determining need to change billing status, requesting additional clinical information from the Utilization Review RNs, and referring cases to the Clinical Appeals team.
Reviews medical record documentation and provides recommendations for denial management based on clinical expertise and payor behaviors.
Partners with leadership and contracting to develop most beneficial language for payor agreements and contracts.
Collaborates with internal and external physician advisor functions by coordinating and facilitating peer to peer assignments.
Collaborates with UR coordinators, clinical appeals, and physician advisors to prevent and manage concurrent denials.
Advocates for the patient and hospital with insurance companies to optimize reimbursement and hospital stay coverage.
Manages all assigned processes in compliance with the Medicare Conditions of Participation including, but not limited to, the W2/121 billing/self-denial process, patient communication regarding UR committee determinations, and communication with external entities as required in the federal and state regulations.
Analyzes key metrics for projects as assigned.
Maintains working knowledge of payor requirements.
Partner with Clinical Appeals team to ensure aligned process for front and back end denial management.
Provide highly effective reconsideration clinicals to payors in order to prevent denials
Facilitates professional communication to ensure the authorization process is completed in a patient centered manner with adherence to quality and timeline standards.
Maintains effective and efficient processes for determining appropriate admission status based on the regulatory and reimbursement requirements of various commercial and government payers.
Maintains knowledge and understanding of applicable federal regulations and Conditions of Participation.
Actively participates in process improvement initiatives, working with a variety of departments and multidisciplinary staff.
Effectively and efficiently manages a diverse workload in a fast-paced, rapidly changing regulatory environment.
Collaborates with other members of the interdisciplinary team as outlined in the system UM Plan
Coordinates communication with physicians and collaborates to ensure appropriate patient status.
This individual identifies, develops, and provides orientation, training, and competency development for appropriate staff and colleagues on an ongoing basis.
Consistently demonstrate ability to serve as a role model and change agent by promoting the concept of teamwork and the revenue cycle process continuum of high performing teams.