At UHS, we're looking for exceptional people who share our vision and values, who share our focus on hard work, enthusiasm, teamwork, loyalty, trust and cooperation. We've embraced these traits and built a team of employees who consistently work to achieve the highest level of service excellence. People are our most valuable resource at UHS as we are committed to providing high quality acute care and behavioral health services to residents of the communities we serve. We are equally committed to offering our employees unlimited opportunity in an environment that encourages professional development.
Under the direction of the Director of Utilization Management the UM Specialist contacts external case managers/managed care organizations for certification and recertification of insurance benefits throughout the patientâ€™s stay, and assists the treatment team in understanding the insurance companyâ€™s requirements for continued stay and discharge planning. The UM Specialist is responsible for having a thorough understanding of the patientâ€™s treatment through communication with the treatment team.Â The UM Specialist advocates for the patientâ€™s access to services during treatment team meetings and through individual physician contact.
Case Management/Utilization Management Duties:
Review the patientâ€™s records and advocate for additional services as indicated.
Promote effective use of resources for patients.
Maintain ongoing contact with the physicians and various members of the team providing updates as needed.
Collaborate with the treatment team regarding continued stay and documentation issues.
Advocate that the patient is placed in the appropriate level of care and program.
Maintain documentation related to UR activities in the appropriate databases.
Assure tracking of insurance reviews, and that reviews are completed in a timely manner.Â Â
Communicate insurance requirements to all levels of staff.
Update the denial log statistics on an ongoing basis (at least weekly), and initiate appeals through telephone or written communication within 7 to 10 days of denial.
Consult with the business office and/or admission staff as needed to clarify data and ensure the insurance precertification process is complete.
Provide clinical information to managed care companies, insurance companies and other third party reviewers to establish the length of stay or number of certified days.
Coordinate with the insurance company doctor in appeals process and denials process.