Utilization Management Specialist-MSH-Case Management-FT-Days

Job Description

Utilization Management Specialist MSH Case Management FT Days

This position is responsible for coordinating requests for clinical information from third party payers and providing support to a broad client base, both internal and external to the institution. Position responsibilities will include utilization management support functions for patient admissions and continuing stay. This position also facilitates and tracks concurrent adverse determinations and collaborates with Appeals Management Department in managing retrospective denials.

Qualifications

• Associate degree required; Bachelor?s degree with coursework in business preferred.

• Familiarity with Third Party Payor requirements preferred.

Non-Bargaining Unit, 329 - Case Management - MSH, Mount Sinai Hospital

Responsibilities

• Admission: Payer Authorization & Denials Management. Communicate with payer to obtain request for clinical information, payer authorization and determination (i.e. frequent communication until case determination is established), follows up at regular interval to ensure payer response. Coordinate peer to peers (i.e. If case is denied, ensure timely peer to peer is scheduled) Data Entry & Reporting. Responsible for all relevant communication with payers (time stamped) and entered into electronic tracking system including the following: Process payer denial correspondence mail, end of day reports and fax, enter payer requests, authorization and determination into tracking system, enter required information and tasks into tracking system to alert CM of need for initial and continued stay reviews, and process continued stay and admission denials. Assign denials to the CMs and MD resource as appropriate.

• Data Entry & Reporting. Oversee collection & integrity of all reported data elements (top-level KPI's; process metrics). Enter all certification and denial data into tracking system based on review of payer communication. Enter in end of day reports, any notification from internal and external case managers and financial screening information.

• Communication Requirements. Communicates with PFS and ensures relevant info available to PFS for billing purposes. Contact insurance companies and set up peer to peer telephone conference. Communication sent to group providing peer-to-peer contact number, patients insurance ID, and DOB. Responsible for incoming communications via phone or fax and monitors office voice mails. Fax denial letters to centralized MSHS denial department within 48 hours of receipt. Generates and distributes payer Census Logs to external clients. Prioritizes incoming communications and relays messages to Case Managers or other UM staff.

• Other Tasks as Required. Performs other daily tasks associated with data entry and reconciliation between the electronic tracking systems, the EMR, the finance system and the admitting systems. Maintains office files, equipment and supplies. Performs other duties as assigned.

About Us

Strength Through Diversity

The Mount Sinai Health System believes that diversity, equity, and inclusion are key drivers for excellence. We share a common devotion to delivering exceptional patient care. When you join us, you become a part of Mount Sinai's unrivaled record of achievement, education, and advancement as we revolutionize medicine together. We invite you to participate actively as a part of the Mount Sinai Health System team by:

• Using a lens of equity in all aspects of patient care delivery, education, and research to promote policies and practices to allow opportunities for all to thrive and reach their potential.

• Serving as a role model confronting racist, sexist, or other inappropriate actions by speaking up, challenging exclusionary organizational practices, and standing side-by-side in support of colleagues who experience discrimination.

• Inspiring and fostering an environment of anti-racist behaviors among and between departments and co-workers.

At Mount Sinai, our leaders strive to learn, empower others, and embrace change to further advance equity and improve the well-being of staff, patients, and the organization. We expect our leaders to embrace anti-racism, create a collaborative and respectful environment, and constructively disrupt the status quo to improve the system and enhance care for our patients. We work hard to create an inclusive, welcoming and nurturing work environment where all feel they are valued, belong and are able to advance professionally.

Explore more about this opportunity and how you can help us write a new chapter in our history!

"About the Mount Sinai Health System:

Mount Sinai Health System is one of the largest academic medical systems in the New York metro area, with more than 43,000 employees working across eight hospitals, more than 400 outpatient practices, more than 300 labs, a school of nursing, and a leading school of medicine and graduate education. Mount Sinai advances health for all people, everywhere, by taking on the most complex health care challenges of our time - discovering and applying new scientific learning and knowledge; developing safer, more effective treatments; educating the next generation of medical leaders and innovators; and supporting local communities by delivering high-quality care to all who need it. Through the integration of its hospitals, labs, and schools, Mount Sinai offers comprehensive health care solutions from birth through geriatrics, leveraging innovative approaches such as artificial intelligence and informatics while keeping patients' medical and emotional needs at the center of all treatment. The Health System includes approximately 7,400 primary and specialty care physicians; 13 joint-venture outpatient surgery centers throughout the five boroughs of New York City, Westchester, Long Island, and Florida; and more than 30 affiliated community health centers. We are consistently ranked by U.S. News & World Report's Best Hospitals, receiving high "Honor Roll" status, and are highly ranked: No. 1 in Geriatrics and top 20 in Cardiology/Heart Surgery, Diabetes/Endocrinology, Gastroenterology/GI Surgery, Neurology/Neurosurgery, Orthopedics, Pulmonology/Lung Surgery, Rehabilitation, and Urology. New York Eye and Ear Infirmary of Mount Sinai is ranked No. 12 in Ophthalmology. U.S. News & World Report's "Best Children's Hospitals" ranks Mount Sinai Kravis Children's Hospital among the country's best in several pediatric specialties. The Icahn School of Medicine at Mount Sinai is ranked No. 14 nationwide in National Institutes of Health funding and in the 99th percentile in research dollars per investigator according to the Association of American Medical Colleges. Newsweek's "The World's Best Smart Hospitals" ranks The Mount Sinai Hospital as No. 1 in New York and in the top five globally, and Mount Sinai Morningside in the top 20 globally.

The Mount Sinai Health System is an equal opportunity employer. We comply with applicable Federal civil rights laws and does not discriminate, exclude, or treat people differently on the basis of race, color, national origin, age, religion, disability, sex, sexual orientation, gender identity, or gender expression. We are passionately committed to addressing racism and its effects on our faculty, staff, students, trainees, patients, visitors, and the communities we serve. Our goal is for Mount Sinai to become an anti-racist health care and learning institution that intentionally addresses structural racism."

EOE Minorities/Women/Disabled/Veterans

Compensation Statement

Mount Sinai Health System (MSHS) provides a salary range to comply with the New York City Law on Salary Transparency in Job Advertisements. The salary range for the role is $23.0137 - $34.2394 Hourly. Actual salaries depend on a variety of factors, including experience, education, and hospital need. The salary range or contractual rate listed does not include bonuses/incentive, differential pay or other forms of compensation or benefits.