Utilization Review Spec – McLaren Careers

Department: Behavioral Health

Shift:

Variable

Daily Work Times: Variable

Scheduled Hours per Pay: 0

Position Summary:

Determines the appropriate admission status based on the regulatory and reimbursement requirements of various commercial and government payers. Partners with the health care team to ensure insurance reimbursement of hospital admissions is appropriately coded and documented, and based on medical necessity. Conducts concurrent reviews of all medical records to ensure criteria for admission and continued stay are met and documented.

Essential Functions and Responsibilities:

1. Performs a variety of concurrent and retrospective utilization management-related reviews and functions to ensure that appropriate data are tracked, evaluated, and reported.

2. Responsible for assuring compliance with governmental, internal, and external agencies’ standards, policies, and procedures for quality and accurate documentation.

3. Collaborates with the health care team to determine the appropriate hospital setting (inpatient vs. observation) based on medical necessity. Actively seeks additional clinical documentation from the physician to optimize hospital reimbursement when appropriate.

4. Works collaboratively with case management to expedite patient discharge.

5. Maintains current knowledge of hospital billing processes and participates in the resolution of retrospective billing issues including appeals, PACER authorization, third party payer certification, and denied cases.

6. Assists with monitoring the effectiveness/outcomes of the utilization management program, identifying and applying appropriate metrics, evaluating the data, reporting results to various audiences, and designing and implementing process improvement projects as needed.

7. Identifies, develops, and provides orientation, training, and competency development for appropriate staff and colleagues on an ongoing basis.

Qualifications:

Required

Bachelor’s degree in HIM/coding/medical records or UM

Coding (CCS) certification within three years of hire

Two years of case management or utilization review, HIM, or coding experience

Preferred:

Three years of recent experience doing third party payer certification.

Nicotine Testing -

To provide

a safe, healthy environment for our patients, employees and visitors, as of

February 1, 2013 McLaren no longer hires individuals who use nicotine and will

conduct nicotine testing during the pre-employment process. If the test is

positive the offer will be rescinded. Individuals who test positive may

re-apply for employment after six months.

Equal Opportunity Employer ofMinorities/Females/Disabled/Veterans

We are committed to encouraging and

sustaining a work environment free of unlawful harassment, discrimination,

and/or retaliation. We are an Affirmative Action/Equal Opportunity

Employer committed to providing employment opportunity without regard to an

individual’s race, color, age, religion, sex/pregnancy (including pregnancy/childbirth

or pregnancy/childbirth-related conditions), sexual orientation, gender

identity, national origin, disability, veteran status, genetic information, or

any other status prohibited by applicable laws. We also make good faith

efforts to recruit, hire, and promote qualified women, minorities, individuals

with disabilities, and veterans.