Utilization Review/Reimbursement Specialist

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Job Description

Job Title: Utilization Review/Reimbursement Specialist

Primary Location: Remote

Department: Admissions/Access

Employment Type: Regular

Compensation Range: $28.70 and goes up based on experience

Hours: Monday - Friday 8:30am -5pm, Weekend rotation every 6-7 weeks

Responsible for coordinating the Medical Record/Utilization Management Policies and Procedures according to standards set by the Hospital, Mary Free Bed Medical Staff, and outside regulatory agencies. This includes the analysis of medical records for documentation justifying the need for post-acute care services.  This position works across the Mary Free Bed network of hospitals to provide insurance authorization services, and extended stay reviews and recommendations to provide access to inpatient rehabilitation when appropriate. The Utilization Review/Reimbursement Specialist is responsible for driving denial management strategies to ensure all appropriate patients have access to Mary Free Bed inpatient programs.​ 

Essential Job Responsibilities  

• ​​Coordinates utilization management review functions as set forth in the Hospital Utilization Review Plan (screening for determination of necessity, eligibility, and appropriateness) at preadmission, admission, continued stay and discharge.    

• ​ Analyzes insurance, governmental, and accrediting agency standards to determine criteria concerning admissions, treatment, and length of stay of patients.  

• ​Manages the completion of prior authorization/recertification calls or faxes to a variety of third-party insurers as a part of the reimbursement process.  

• ​Complex case reviews for determination of inpatient admission criteria. 

• ​Implements strategies to navigate insurance authorization process efficiently. 

• ​Responsible for robust data capture through documentation of denial management activities and outcomes. 

• ​Assists manager in the following areas:  

• ​Departmental and hospital-wide educational activities.  

• ​Review and refinement of Utilization Review policies and procedures.  

• ​Medical chart review and composition of insurance appeal letters on behalf of patients.  

• ​Develops and maintains relationships with key payers to improve access to inpatient services at Mary Free Bed. 

• ​Admission office duties as assigned by the supervisor 

• ​We’ll embrace all people by: 

​Treating everyone with dignity and respect. 

​Opening more doors to opportunity for others to succeed. 

​Growing talent and people. 

​Ensuring a welcoming experience for all we serve, regardless of origin, race, religion, disability, sexual orientation or socioeconomic status. 

​Taking action against discrimination. 

​Honoring our differences and how we collaborate. 

​Educating staff, patients and the communities we care for. 

​Restoring hope and freedom, together​ 

Customer Service Responsibilities  

Demonstrate excellent customer service and standards of behaviors as well as encourages, coaches, and monitors the same in team members. This individual should consistently promote teamwork and direct communication with co-workers and deal discretely and sensitively with confidential information. 

Responsibilities in Quality Improvement  

Contribute by identifying problems and seeking solutions. Promote patient/family satisfaction where possible; participates in departmental efforts to monitor and report customer service. 

Essential Job Qualifications  

• Degree in nursing, social work, physical therapy, occupational therapy, speech therapy, athletic trainer, or equivalent degree. 

• Valid driver’s license with no restrictions   

• Demonstrated competence in spelling, grammar, and composition and able to type accurately.  

• Ability to interact with professional staff in an appropriate manner.  

• Demonstrated competence in the use of a personal computer for development and use of appropriate Medical Records, Admissions, and Utilization Management applications.  

Preferred Job Qualifications 

• A minimum of 2 years’ experience in Utilization Management 

• Certification as a Registered Health Information Technician or Registered Health Information Administrator a plus 

Physical Requirements for Essential Job Qualification 

Levels: 

• None (No specific requirements) 

• Occasionally (Less than 1/3) 

• Frequently (1/3 to 2/3) 

• Majority (More than 2/3) 

Remain in a stationary position: ​Majority 

Traverse or move around work location: ​Occasionally 

Use keyboard:  ​Frequently 

Operate or use department specific equipment:  ​None 

Ascend/Descend equipment or ladder: ​None 

Position self to accomplish the Essential Functions of the role: ​None 

Receive and communicate information and ideas for understanding: ​None 

Transport, position, and/or exert force:  

Up to 10 pounds:   ​Occasionally 

Up to 25 pounds: ​ _____ 

Up to 50 pounds: ​ _____ 

Up to 75 pounds:  ​ _____ 

More than 100 pounds: ​ _____ 

Other weight: Up to___ pounds ​ _____

Other: ​None 

Consistent with the Americans with Disabilities Act (ADA), it is the policy of Mary Free Bed Rehabilitation Hospital to provide reasonable accommodation when requested by a qualified applicant or employee with a disability, unless such accommodation would cause an undue hardship. The policy regarding requests for reasonable accommodation applies to all aspects of employment, including the application process. If reasonable accommodation is needed, please contact the Talent Acquisition team at recruitment@maryfreebed.com. 

Mary Free Bed is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, national origin, age, genetic information, veteran status, disability or other legally protected characteristic.