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Collects multifaceted data, analyzes information, and makes recommendations which drive decision making.
MINIMUM QUALIFICATIONS
EDUCATION, CERTIFICATION, AND/OR LICENSURE:
- Bachelor’s degree
EXPERIENCE:
- Two (2) years of experience in Healthcare Field.
PREFERRED QUALIFICATIONS
EDUCATION, CERTIFICATION, AND/OR LICENSURE:
- Master’s degree (Public Health, Healthcare Administration, or Business Administration)
EXPERIENCE:
- EPIC experience
CORE DUTIES AND RESPONSIBILITIES:
The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.
- Assists with collection of data through various methods such as chart review of patients, Utilization Management platforms, aggregates data, analyzes for trends, and recommends action items.
- Identifies strategic opportunities for improving departmental operations of the key performance metrics.
- Coordinates requested audits from the utilization review committee and provides analysis to physician and department leadership.
- Stays abreast of updates and changes to regulatory updates, regulatory requirements, and organizational compliance policies.
- Knowledgeable on the department core workflows and provides opportunities for improvement related to efficiency and better outcomes.
- Tracks and validates accuracy and provides timely response to projects.
- Maintains current knowledge of utilization review process, including denials and concurrent reviews. Recommends processes to leadership for improvement.
- Accurately interprets data definitions and communicates both verbally and in writing to key leaders to facilitate improvements.
- Collaborates in the ongoing redesign and re-engineering of Utilization Management functions, to meet the changing needs and priorities of the organization.
- Develops reporting mechanisms to monitor and report on utilization, productivity, and outcomes for implementation and improvement strategies.
- Educates and serves as subject matter expert for the use of software programs that support utilization management processes. Guides and assists I.T. partners with maintenance, development, and upgrades of utilization management software; serving as content expert and communicating department needs.
- Provides input in the development of the utilization review committee agenda and data necessary for meaningful committee participation in utilization management efforts. Adheres to organization and department specific safety, confidentiality, values, policies, and standards.
PHYSICAL REQUIREMENTS:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
WORKING ENVIRONMENT:
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
SKILLS AND ABILITIES:
- Considerable knowledge of computers and the use/manipulation/application of data in support of administrative functions.
- Knowledge of EPIC system is preferred.
- Knowledge of Medicare, Medicaid, and other regulatory requirements.
- Knowledge of UB-04, itemized bills, insurance plans (i.e. Commercial Medicare, Medicaid, HMO, PPO, etc.), grievance procedures and utilization management processes required.
- Knowledge of managed care, inpatient and outpatient care, utilization management, Interqual criteria.
- Knowledge of the operations of patient billing is required.
- Knowledge of medical terminology and the ability to interpret information in the medical record is required.
- Knowledge of CPT, ICD9/10, and DRGs.
- Previous experience in administrative or supervisory role.
- Effective organizational skills, attention to detail, ability to take initiative, and excellent follow-through a must.
- Ability to function as a team player and support colleagues and staff is essential.
- Ability to hold others accountable to performance related to lost revenue due to denials.
- Expert level computer skills including Excel and other Microsoft products.
Additional Job Description:
Scheduled Weekly Hours: 40
Shift: Day (United States of America)
Exempt/Non-Exempt: United States of America (Exempt)
Company: WVUH West Virginia University Hospitals
Cost Center: 553 SYSTEM Utilization Review
Address: Pennsylvania State, Harrisburg, Pennsylvania
