Utilization Review Specialist at Willis-Knighton Health System – Shreveport, Louisiana

UTILIZATION REVIEW SPECIALIST

Purpose of Job Position:

Responsible for ensuring appropriate communication with third-party payers to authorize hospital stays. Gathers clinical information for submission to complete timely, high-quality initial and continued reviews. Communicates this information with providers, payors, Floor Case Managers, and appropriate Business Office staff. Works to avoid any hospital stay denials with third-party payers.

Major Duties:

• Properly utilize the electronic medical record to generate daily worklists that are accurate and up-to-date.
• Performs high-quality initial and subsequent reviews and submits information timely to third-party payers to obtain authorization for hospital stays.
• Upon identification of possible denials, forward information to the appropriate business office staff members and supervisor.
• Contact third-party payers throughout admission and after the patient is discharged if needed to determine the number of approved/denied days.
• Complies with federal and state regulations regarding utilization review functions and scope of practice.
• Utilizes departmental policies and procedures to complete work in a timely and high-quality manner.
• Adheres to health system standards to ensure confidentiality of patient and department information.
• Utilizes all available methods for communicating information up to and including telephone, fax, intranet, internet, and e-fax.
• Maintains daily contact with case managers, registration staff, precertification, the business office, and providers as appropriate.
• Proactively follow up with third-party payers to determine information needs and the status of assigned claims.
• Provides information to third-party payers, home health agencies, post-acute service providers, government agencies and others applicable to utilization review requests and determinations.
• Submits all reports and data requested in a timely manner.
• Attends and participates in department meetings.
• Displays a caring and courteous attitude and represents the health system in a positive manner to all people.
• Assume responsibility for your own continuing education.
• Adheres to department and hospital dress codes, safety policies and procedures.
• Compliance with the policies and procedures of the Willis Knighton Health System Code of Conduct and service quality standards
• Compliance with patient safety and quality initiatives as appropriate for job description.
• Employee will consistently and effectively use the C.I. CARE framework when interacting with patients, guests, and colleagues.

QUALIFICATIONS:

Degree in healthcare-related field preferred

2 years of clinical experience preferred

Experience in precertification and authorizations preferred.

Competent in the following:

• Effective communication
• Problem-solving
• Stress management
• Computer skills
• Attention to detail
• Demonstrates flexibility
• Ability to express ideas both verbally and in writing