Utilization Management Specialist - FT, Days

Essential Functions

• All team members are expected to be knowledgeable and compliant with Prisma Health's purpose:  Inspire health.  Serve with compassion.  Be the difference.

• Runs daily, weekly, monthly and quarterly reports

• Obtains and submits appropriate clinical documentation to the payors.  Responds to payor requests for additional documentation timely and accurately. 

• Updates and maintains authorization numbers and approved days in registration and/or case management systems

• Obtains appropriate statistical data for patients in assigned patient population areas and communicates data to payors

• Enters payor denial data into denial management or case management system

• Answers, screens and prioritizes telephone calls, utilizing sound judgement regarding the urgency and content of the information

• Processes faxes to and from payers for the Case Management team as assigned.

• Secures discharge dates for payers.

• Provides assistance with the discharge planning process including but not limited to sending information to receiving information from appropriate vendors/providers.

• Ensures data entry is completed timely and accurately.

• Ensures payor communication is completed timely and accurately.

• Performs other duties as assigned.

Supervisory/Management Responsibilities

• This is a non-management job that will report to a supervisor, manager, director or executive.

Minimum Requirements

• Education - High School diploma or equivalent. Associate degree in Business or Healthcare related field of study preferred

• Experience - Two (2) years of clerical or administrative experience

In Lieu Of

• NA

Required Certifications, Registrations, Licenses

• NA

Knowledge, Skills and Abilities

• Basic understanding of common medical and financial terminology preferred