Utilization Management Specialist

This position supports the Utilization Management (UM) team, focusing on specific areas of the overall UM process. This position will develop a deep understanding of all PrimeWest Health’s regulatory and business needs and will conduct business in an efficient manner.

A.    Reporting Accountability 
This position is responsible for meeting the following regulatory, contractual, or other requirements on behalf of PrimeWest Health:
1.    Ensure health care records are maintained and shared in accordance with all Minnesota Department of Human Services (DHS) and Centers for Medicare & Medicaid Services (CMS) regulations and policies
2.    Ensure compliance with all regulatory and contractual requirements related to the Quality & Utilization Management department

B.    Role and Key Responsibilities
Assist the Utilization Management Manager and PrimeWest Health staff in the following as needed:
1.    Serve as lead UM specialist, providing training and ongoing support for new UM specialists 
2.    Serve as lead for filing and processing nursing home and Swing Bed admissions and discharges 
3.    Triage phone calls related to UM 
4.    Ensure that the UM phone line voice message is up to date 
5.    Serve as backup for filing and processing of dental- and pharmacy-related authorization requests 
a.    Send documentation to dental and pharmacy staff reviewers with appropriate information and communicate outcome of review to provider
6.    Assist UM team with printing and mailing UM-related materials and documentation that has been entered into CareConnect (CCNT)
7.    Provide internal coding assistance and research coding questions for the Quality & Utilization Management and Care Management departments
8.    Troubleshoot pharmacy-related issues for providers
9.    Assist UM care coordinators with data entry into CCNT. This includes starting events for requests received by phone, fax, or mail and assigning the event to the appropriate UM care coordinator or behavioral health care coordinator as appropriate for medical review 
10.    Assist in the timely processing of Service Authorization requests sent via electronic fax including receiving/retrieving faxes and documentation from the M-Files electronic fax system, attaching documents to member files in CCNT, and triaging urgent reviews to the appropriate UM care coordinator
11.    Verify protected health information (PHI) prior to mailing
12.    Assist with miscellaneous UM-related projects and initiatives

 
C.    General PrimeWest Health Responsibilities
1.    Abide by the PrimeWest Health Code of Conduct
2.    Comply with all PrimeWest Health policies and procedures
3.    Comply with the Health Insurance Portability and Accountability Act (HIPAA) and all other privacy laws
4.    Be familiar with building safety procedures and alert maintenance if something requires attention
5.    Keep public areas of the department and office neat and clean
6.    Conduct other responsibilities and activities as needed and assigned

D.    Professional Competencies – N/A

E.    Educational Requirements and Required Qualifications
1.    At minimum, knowledge of medical billing and procedures.
2.    Demonstrated knowledge of, and proficiency in, Word, Excel, and Outlook required. Experience in Access is a plus.
3.    Flexibility and ability to handle multiple tasks. Demonstrated organizational skills and attention to detail. Ability to work effectively with a variety of people both within and outside of the organization. Good verbal and written communication skills.
4.    Ability to sit at a desk or computer station most of the time. Ability to occasionally lift and/or carry such articles as file folders and small boxes up to 30 pounds. 

F.    Appropriate Licensure and Certification Requirements 
1.    Current coding certification is preferred.
2.    Must attend continuing education sessions each year to support certification requirement if applicable.

G.    Collaborative Efforts with Other Departments 
1.    Administrative Services
2.    Business IT Research & Development
3.    Care Management 
4.    Communications
5.    Compliance
6.    Information Systems & Technology
7.    Membership & Program Development 
8.    Provider Network Administration 

H.    Supervision – N/A

This position description is not to be construed as an exhaustive statement of essential functions or responsibilities.

Location: Alexandria, Minnesota

PrimeWest Health will accept resumes for this position through August 3, 2018. No phone inquiries please. Employment to begin approximately August 13, 2018.