System Utilization Management SUM Specialist

SUMMARY: The System Utilization Management Specialist (UMS) will play a pivotal role in supporting the Utilization Management (UM) team across all three AHS campuses. The UMS will report directly to the UM Manager. This multifaceted position will focus on both clinical and administrative functions within the UM department, ensuring seamless operations and effective management of utilization processes.

DUTIES & ESSENTIAL JOB FUNCTIONS: NOTE: Following are the duties performed by employees in this classification. However, employees may perform other related duties at an equivalent level. Not all duties listed are necessarily performed by each individual in the classification. 

• Payer Liaison:  Serve as the primary point of contact for all insurance-related inquiries and interactions. Facilitate clear and accurate communication between the UM department and payers, addressing issues, sending clinical information, and ensuring timely processing and receipt of Inpatient authorizations and/or denials. 

• Fax Management: 
  • Check all UM fax folders daily to ensure timely receipt and sending of documents. 
  • Ensure that clinical documentation is faxed to and received by all payers to support inpatient admissions and/or denials.  

• Maintain accurate records of all fax communications.

• Optum Portal Management:  Check Optum Portal frequently throughout the day to ensure that all determinations are addressed and uploaded to the EPIC charts. 

• Authorization Management:
  • Obtain initial and concurrent inpatient authorizations from insurance companies for all inpatient admissions. 
  • Track the status of authorization requests and follow up with insurance companies, as needed. 
    • Confirm patient’s insurance coverage and benefits, as requested. 
    • Accurately document all communication with insurance companies in EPIC. 
    • Maintain detailed records of authorization requests, approvals and inpatient denials. 
    • Update UR team on the status of authorizations, as required. 
    • Maintains current database of payor contact information. 

• Data Entry and Reporting:  Perform accurate data entry into the EHR, ensuring data integrity.

• Multitasking and Prioritization: 
  • Manage multiple tasks and responsibilities effectively in a fast-paced, ever-changing environment. 
  • Prioritize tasks to meet deadlines and support the needs of the department. 

• Administrative Support:
  • Provide comprehensive administrative assistance to the Utilization Review (UR) team. 
  • Assist with other duties, as assigned. 
  • Participate in new staff onboarding, as needed.  
  • May have to float throughout the system to different locations.

MINIMUM QUALIFICATIONS:

• Required Education: Associate degree is required, OR equivalent years of experience, as typically found in 2-3 years of health education in an inpatient, skilled nursing, home health, health plan or related setting.  
• Preferred Education: Equivalent experience will be accepted in lieu of the required degree or diploma.  
• Required Experience: Minimum three (3) years in health care setting working directly with interdisciplinary team/patients/families in a clinical team setting.  Hospital and/or Health Plan experience.  
• Preferred Experience: Experience coordinating benefits, obtaining authorizations, Hospital experience.