Utilization Management Specialist Jobs in Sarasota at PuzzleHR
Title: Utilization Management Specialist
What’s in it for you?
Great benefits package
Fantastic PTO package
Utilization Management SpecialistSalary: $17+ hourlyPosition Summary:The Utilization Management Specialist is responsible to collaborate with healthcare providers and members to promote quality member outcomes, optimize member benefits, and promote effective use of resources. Accurately interprets benefits and managed care products, and steers members to appropriate providers, programs, or community resources. Strong people skills to provide excellent internal and external customer service; Ability to multi-task, pay attention to detail. Organizational, time management, problem solving, crisis management skills as well as flexibility, creativity, and the ability to manage stress
Conducts pre-certification, continued stay review, care coordination, or discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts, in collaboration with the treatment team.
Ensures member access to medically necessary, high-quality healthcare in a cost-effective setting according to contract.
Consult with clinical and/or medical staff daily to ensure medically appropriate, high-quality, cost-effective care throughout the utilization management process.
Collaborates with providers to assess members’ needs for early identification of and proactive planning for discharge planning.
Recommends resource utilization.
Prioritizes and organizes work to meet changing priorities.
Utilizes analytical ability required to gather data. Uses clinical judgment to apply predetermined criteria or uses independent clinical judgment when no predetermined criteria exists to identify problems, facilitate resolution, recommend corrective action, and report results effectively.
Uses independent clinical judgment in reviewing records to determine status of patients stay, if proper procedures have been followed, seriousness of incidents and ability to identify need for and participate in focused reviews, special projects and identify opportunities for improvement.
Makes recommendations regarding appropriateness of the treatment plan for continued stay and safety of the discharge plan.
Achieves a minimum of 85% on Internal Rate of Return quarterly.
Completes Utilization Management for assigned patients with a minimum of 25-30 reviews per day.
Applies medical necessity guidelines accurately to monitor appropriateness of admission and continued stays.
Follows department guidelines on escalation processes and refer cases appropriately to the internal or external stakeholder.
Maintains professional work standards including confidentiality, ethical principles, and professional work habits.
Maintains and supports collaborative relationships with finance, Physicians and the multidisciplinary teams.
Documents appropriately in UM notes to provide evidence that the UR process for the case was followed.
Education & Experience:
Bachelor’s Degree in Behavioral Sciences/Social Work/Counseling/Psychology, or related field is required.
Two or more years of experience in insurance utilization review is required.
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