Hours: 8:30AM - 4:30PM
Days: Monday - FridayÂ
JOB SUMMARY
The utilization management specialist/analyst is responsible for supporting utilization management functions for more complex cases, as needed. Completes utilization reviews for medical necessity, as needed. Reviews acute inpatient cases, communicating needs related to billing and coding issues. Timely completes accommodations and adjustments, as indicated. Ensures patient status orders are entered timely. Works with payers to obtain information needed, to avoid delays in payment. Collaborates often with members of the healthcare team, as well as partners from various Hamilton departments. The utilization management specialist/analyst will also assist, as needed, as the case management point of contact for clinical denials and appeal inquiries. The utilization specialist/analyst will review each case identified/referred for appeal, based on InterQual and/or other relevant guidelines, determine the viability of the appeal, and assist in the appeal process. Working with Case Management leadership, the utilization management specialist/analyst will orchestrate education, complete focused audits, gather data for reporting, extracts data for analysis and interpretation, and other performance improvement initiatives to impact clinical quality, improve efficiency and mitigate lost revenue related to medical necessity denials. The utilization management specialist/analyst will also work with case management leadership, ensuring case management functions are completed per policies, procedures, and in accordance to the requirements of Centers for Medicare and Medicaid Services (CMS), the Joint Commission (TJC), and Georgia Department of Community Health (DCH).
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Serves as an active member of the Utilization Management Committee, and regularly report Key Performance metrics.
