Utilization Management Specialist-MSH-Case Management-FT-Days

Utilization Management Specialist MSH Case Management FT Days EOW 

This position is responsible for coordinating requests for clinical information from third party payers and providing support to a broad client base, both internal and external to the institution. Position responsibilities will include utilization management support functions for patient admissions and continuing stay. This position also facilitates and tracks concurrent adverse determinations and collaborates with Appeals Management Department in managing retrospective denials.

1. Admission: Payer Authorization & Denials Management. Communicate with payer to obtain request for clinical information, payer authorization and determination (i.e. frequent communication until case determination is established),follows up at regular interval to ensure payer response. Coordinate peer to peers (i.e. If case is denied, ensure timely peer to peer is scheduled)


2. Data Entry & Reporting. Responsible for all relevant communication with payers (time stamped) and entered into electronic tracking system including the following: Process payer denial correspondence mail, end of day reports and fax, enter payer requests, authorization and determination into tracking system, enter required information and tasks into tracking system to alert CM of need for initial and continued stay reviews, and process continued stay and admission denials. Assign denials to the CMs and MD resource as appropriate.


3. Data Entry & Reporting. Oversee collection & integrity of all reported data elements (top-level KPI's; process metrics). Enter all certification and denial data into tracking system based on review of payer communication. Enter in end of day reports, any notification from internal and external case managers and financial screening information.


4. Communication Requirements. Communicates with PFS and ensures relevant info available to PFS for billing purposes. Contact insurance companies and set up peer to peer telephone conference. Communication sent to group providing peer-to-peer contact number, patients insurance ID, and DOB. Responsible for incoming communications via phone or fax and monitors office voice mails. Fax denial letters to centralized MSHS denial department within 48 hours of receipt. Generates and distributes payer Census Logs to external clients. Prioritizes incoming communications and relays messages to Case Managers or other UM staff.


5. Other Tasks as Required. Performs other daily tasks associated with data entry and reconciliation between the electronic tracking systems, the EMR, the finance system and the admitting systems. Maintains office files, equipment and supplies. Performs other duties as assigned.

• Associates degree or equivalent combination of experience (Bachelors preferred).


• 2 or more years of relevant experience.

Non-Bargaining Unit, 329 - Case Management - MSH, Mount Sinai Hospital