Yale New Haven Health System

  • UTILIZATION REVIEW SPECIALIST

    Job Locations US-CT-New Haven
    Job ID
    66286
    Department
    UTIL MGMT/REVENUE RECOVERY
    Category
    RN/NURSING - ALL OTHER
    Position Type
    Full Time Benefits Eligible
    Scheduled Hours
    40
    Work Schedule
    DAYS
    Work Days
    MONDAY THROUGH FRIDAY
    Work Hours
    8-430PM
    Work Shift
    N/A
    Requisition ID
    2018-20307
  • Overview

    To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values—integrity, patient-centered, respect, accountability, and compassion—must guide what we do, as individuals and professionals, every day.

    Under the general direction of the Manager Utilization Management/Revenue recovery, the Utilization Review Specialist/RAC Liaison (URS/RL) performs a wide range of utilization review and management activities in an attempt to prevent insurer denials, enhance revenue, and to recover payment for services that have been denied. Responsible for the collection of denial and appeal data as well as other clinical documentation when necessary. The URS/RL works collaboratively with other members of the UM/RR department, health care team, Care Coordination, PFAS, HIM, Contracting and SBO towards process improvement to avoid denials.

    EEO/AA/Disability/Veteran

    Responsibilities

    • 1. Ensures that inpatient clinical payor denials are reviewed for appeal potential. Files formal appeals with the payors requesting reconsideration of the denied services.
    • 2. Establishes a system to follow up with payers/managed care organizations regarding outstanding denials and addresses identified payor issues
    • 3. Acts as a consultant and resource to the financial and care coordination departments regarding utilization insurance and payer issues.
    • 4. Responds to audits and inquires not limited to OIG, IPRO, QIO and RAC. Documents accordingly in EPIC and/or SSI RADs as indicated.
    • 5. Works with our members of our PFAS Department on Inpatient technical denials and precertification issues.
    • 6. Identifies trends and consistent barriers and work with the SBO Management Teams and the YNHHS health care team to support resolution. Intervene when necessary to correct delays and eliminate/reduce negative financial outcomes. Collaborates with appropriate individuals and departments to ensure appropriate reimbursement.
    • 7. Communicate as needed with , MDS, payors and governmental contractual agencies regarding denials and appeals. Develop strong working relationships with payors to support collaborative efforts in ensuring hospital reimbursement.
    • 8. Works collaboratively with the SBO to support monthly documentation of provider liable dollars. Tracks, documents and reports denials and appeals by payor. In collaboration with Manager of the department developed a statistical tracking system that supports the quantification of all department activities, cost avoidance strategies, and denial appeal facilitation.
    • 9. Assists with the clinical FAX Review Program during absences or busy periods and other monitoring activities, research and/or special projects as needed.
    • 10. Along with other members of the health care clinical and financial team, act as a patient advocate to support ongoing medical intervention and treatment. Exhibit awareness of ethical/legal/confidential issues concerning patient care and treatment and support the adherence to such practice.
    • 11. Attends Ad Hoc and regular meetings of both the hospital and system Utilization Review and Denial Committees.
    • 12. Performs miscellaneous duties as required or requested.
    • *cb

    Qualifications

    EDUCATION

     

    (number of years and type required to perform the position duties): Current licensure in the State of Connecticut as Registered Nurse. Masters Degree preferred.

     

    EXPERIENCE

     

    Strongly preferred a minimum of five years of relevant clinical experience in hospital acute care along with relevant experience in case management, care coordination, and/or utilization management in a hospital or insurance setting. Strongly preferred knowledge of finance and billing practices.

     

    SPECIAL SKILLS

     

    Excellent communication, negotiation and organizational skills. Adaptability to a wide variety of interpersonal encounters with the entire hospital team. Comprehensive understanding in use of medical record to extract data. Working knowledge of third party and prospective payment systems. Computer/PC literacy required. Proficient in Microsoft Office including Word, Excel, Access and PowerPoint. Will be trained in use of professionally recognized criteria, ICD-9-CM Coding, Diagnostic Related Grouping (DRG). Must be able to work collaboratively and independently. Must be flexible with responsibilities in order to meet departmental needs.

     

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