[Hiring] Utilization Management Specialist @Vanderbilt University Medical Center

Role Description

Facilitates optimal reimbursement through accurate certification and complete chart documentation ensuring that the appropriate admission status is ordered. Conducts initial admission based on utilization review medical necessity criteria. Refers cases for secondary review when appropriate. Refers and consults with the multidisciplinary team to promote appropriate communication in the absence of definitive documentation and/or review criteria to support hospital stay.

Key Responsibilities

• Facilitates optimal reimbursement through certification and denial processes.
• Facilitates throughput of patients admitted urgently or emergently through the emergency department.
• Participates as an active partner with multidisciplinary team members to ensure case is in the appropriate level of care setting.
• The responsibilities listed are a general overview of the position and additional duties may be assigned.

Technical Capabilities

• Medical Terminology & Documentation (Novice): Possesses sufficient fundamental proficiency to successfully demonstrate medical terminology and documentation in practical applications of moderate difficulty.
• Clinical Applications Systems (Novice): Possesses fundamental proficiency in utilization review systems, clinical support systems and business support applications as needed.
• Utilization Review (Intermediate): Demonstrates expertise of utilization review in practical applications of a difficult nature. Possesses sufficient knowledge, training, and experience to independently complete clinical review to obtain payor authorization. Demonstrates mastery in InterQual Level of Care Criteria and Milliam Care Guidelines. Able to train and educate by setting the example, giving technical instruction, providing leadership, and generally raising the level of performance of others while on the job.
• Interdisciplinary Education (Novice): Seeks to provide education by collaborating with providers and other members of the health care team to ensure that the patient is placed in the appropriate level of care setting.

Core Accountabilities

• Organizational Impact: Executes job responsibilities with the understanding of how output would affect and impact other areas related to own job area/team with occasional guidance.
• Problem Solving/ Complexity of work: Analyzes moderately complex problems using technical experience and judgment.
• Breadth of Knowledge: Has expanded knowledge gained through experience within a professional area.
• Team Interaction: Provides informal guidance and support to team members.

Core Capabilities

• Supporting Colleagues:
  • Develops Self and Others: Invests time, energy, and enthusiasm in developing self/others to help improve performance and gain knowledge in new areas.
  • Builds and Maintains Relationships: Maintains regular contact with key colleagues and stakeholders using formal and informal opportunities to expand and strengthen relationships.
  • Communicates Effectively: Recognizes group interactions and modifies one's own communication style to suit different situations and audiences.
• Delivering Excellent Services:
  • Serves Others with Compassion: Seeks to understand current and future needs of relevant stakeholders and customizes services to better address them.
  • Solves Complex Problems: Approaches problems from different angles; identifies new possibilities to interpret opportunities and develop concrete solutions.
  • Offers Meaningful Advice and Support: Provides ongoing support and coaching in a constructive manner to increase employees' effectiveness.
• Ensuring High Quality:
  • Performs Excellent Work: Engages regularly in formal and informal dialogue about quality; directly addresses quality issues promptly.
  • Ensures Continuous Improvement: Applies various learning experiences by looking beyond symptoms to uncover underlying causes of problems and identifies ways to resolve them.
  • Fulfills Safety and Regulatory Requirements: Understands all aspects of providing a safe environment and performs routine safety checks to prevent safety hazards from occurring.
• Managing Resources Effectively:
  • Demonstrates Accountability: Demonstrates a sense of ownership, focusing on and driving critical issues to closure.
  • Stewards Organizational Resources: Applies understanding of the departmental work to effectively manage resources for a department/area.
  • Makes Data Driven Decisions: Demonstrates strong understanding of the information or data to identify and elevate opportunities.
• Fostering Innovation:
  • Generates New Ideas: Proactively identifies new ideas/opportunities from multiple sources or methods to improve processes beyond conventional approaches.
  • Applies Technology: Demonstrates an enthusiasm for learning new technologies, tools, and procedures to address short-term challenges.
  • Adapts to Change: Views difficult situations and/or problems as opportunities for improvement; actively embraces change instead of emphasizing negative elements.

Qualifications

• LIC-Registered Nurse - Licensure-Others
• Relevant Work Experience
• Experience Level: 1 year
• Education: Bachelor's

Benefits

• Affordable High Quality Health Plan Options
• Dental and/or vision plan
• 403 (b) retirement plan
• Paid Time off (flex PTO)
• Tuition Reimbursement and adoption assistance (maximums applied)
• Short-Long term disability
• Subsidized backup childcare
• And many more...