Under the guidance of the Case Manager, the Lead Utilization Specialist is responsible for serving as a resource for internal and external customers who deal with third party payors including Medicare and Medicaid.

PRINCIPAL DUTIES AND RESPONSIBILITIES(*Essential Functions)

1. Advises all appropriate departments of current regulations that apply to private payors as well as Federal and State requirements.
2. Assists hospital attorney with court cases through chart reviews and verbal and written communication.
3. Coordinates responses to the Peer Review Organization as it relates to both medical and hospital concerns.
4. Appeals hospital cases that have been denied payment to the appropriate third party payor.
5. Provides outcome data such as number of appeals and confirms quality issues through computer data entry.
6. Defines and interprets hospital policies in relations to government regulations as required.
7. Interprets and advises, through written and verbal communication, internal and external customers on issues of reimbursement and regulations.

JOB SPECIFICATIONS(Minimum Requirements)

KNOWLEDGE, SKILLS, AND ABILITIES

• Demonstrates principles of excellent customer service and respond positively to the needs of patient and family.
• Knowledge of government regulations that affect the operations of the hospital.
• Knowledge of Diagnosis Related Group (DRG) coding to serve as a consultant to the Utilization Specialist.
• Excellent communication skills both verbally and in writing.
• Excellent interpersonal and problem-solving skills to negotiate sensitive issues.
• Proficient in abstract appropriate data from medical records to appeal denied cases to third party payors.
• Must be able to analyze data and prepare action plans based on the data.
• Ability to read publications and medical records and to interpret complex material and how it relates to the customers.

EDUCATION

• Bachelors Nursing Required
• 6 Years RN Required Licensed Registered Nurse
• Certified Cardiac Pulmonary Resuscitation

STANDARDS OF BEHAVIOR
Meets the Standards of Behavior as outlined in Personnel Policy and Procedure #1, Employee Relations Code.

CONFIDENTIALITY/HIPAA/CORPORATE COMPLIANCE
Demonstrates knowledge of procedures for protecting and maintaining security, confidentiality and integrity of employee, patient, family, organizational and other medical information. Understands and supports the commitment of Methodist Hospitals in adhering to federal, state and local laws, rules and regulations governing ethical business practices for healthcare providers.

DISCLAIMER - The above statements are intended to describe the general nature and level of work being performed by people assigned to this job. The statements are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required.