Utilization Review/Reimbursement Specialist

  • Grand Rapids, MI
  • Mary Free Bed Rehabilitation Hospital
  • Access
  • Full-Time - Days - 8a-5p
  • Posted: February 5, 2020
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We have the great privilege of helping patients and families re-build their lives. It’s extraordinarily meaningful work and the reason we greet the day with optimism and anticipation. When patients “Ask for Mary,” they experience a culture that has been sculpted for more than a century. Our hallmark is to carefully listen to patients and innovatively serve them. This is true of every employee, from support staff and leadership, to clinicians and care providers. 

Mary Free Bed is a not-for-profit, nationally accredited rehabilitation hospital serving thousands of children and adults each year through inpatient, outpatient, sub-acute rehabilitation, orthotics and prosthetics and home and community programs. With the most comprehensive rehabilitation services in Michigan and an exclusive focus on rehabilitation, Mary Free Bed physicians, nurses and therapists help our patients achieve outstanding clinical outcomes. The growing Mary Free Bed Network provides patients throughout the state with access to our unique standard of care.  

Mission Statement
Restoring hope and freedom through rehabilitation.

Summary:
Responsible for coordinating and/or carrying out the Medial Record/Utilization Management Policies and Procedures, according to standards set by the Hospital, Mary Free Bed Medical Staff and outside regulatory agencies.

Essential Job Responsibilities:

  • Coordinates utilization management review functions as set forth in the Hospital Utilization Review Plan (screening for determination of necessity, eligibility and appropriateness) at preadmission, admission, continued stay and discharge.  This includes acute inpatient rehabilitation as well as sub-acute rehabilitation.
  •  Analyzes insurance, governmental, and accrediting agency standards to determine criteria concerning admissions, treatment, and length of stay of patients.
  • Coordinates the completion of prior authorization/recertification calls or faxes to a variety of third party insurers as a part of the reimbursement process.
  • Assists manager in the following areas:
    • Departmental and hospital-wide educational activities.
    • Review and refinement of Utilization Review policies and procedures.
    • Chart review/letter writing for insurance medical necessity appeals.
  • Develops and maintains relationships with key payers to improve access to inpatient services at Mary Free Bed.       

Other Job Responsibilities:

  • Compares inpatient medical records to established criteria and confers with medical and nursing personnel and other professional staff to determine legitimacy of treatment and length of stay.
  • Refers case to facility physician advisor for review and course of action when case fails to meet admission/continued length of stay standards. 
  • Determines patient review dates according to established diagnostic criteria.
  • Coordinates third party insurer physician peer to peer review/appeals.
  • Assigns ICD-10-CM admission code at time of prior authorization.
  • Develops initial drafts of procedural changes in Utilization Review.

Essential Job Qualifications (Knowledge, Education, and Training Requirements):

  • Certification as a Registered Health Information Technician or Registered Health Information Administrator or Nursing Licensure (RN, LPN).
  • A minimum of 2 years’ experience in Utilization Management preferred, although consideration given to nursing experience as an LPN or RN.
  • Demonstrated competence in spelling, grammar and composition and able to type accurately and consistently at 60 w.p.m.
  • Ability to interact with professional staff in an appropriate manner.
  • Demonstrated competence in the use of a personal computer for development and use of appropriate Medical Records, Admissions, and Utilization Management applications.
  • Physical demands
    • Able to exert up to 10 pounds of force occasionally (up to 1/3 of the time)
    • Able to lift, carry, push, pull, up to 10 pounds occasionally
    • Able to sit for the majority of the time, but may involve brief periods of time involving walking or standing.
    • Able to use keyboard frequently (1/3 to 2/3 of the time)

 

Mary Free Bed is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, national origin, age, genetic information, veteran status, disability or other legally protected characteristic.

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