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Job Field: Legal Jobs
Location: LAKEWOOD, WA
Salary: $-
Job Type: Part Time

JOB SUMMARY:

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               <td align="left"><font style="font-size: 100%;">Title: Utilization Management Specialist on call - FSS (22252)<BR>Location: WA-Tacoma-St Joseph Medical Center<BR>Job Number:_1200020820<BR>Job Summary: <BR><BR>As a member of a multidisciplinary team, provides expertise and guidance in the principles of utilization management resulting in, the evaluation of the medical necessity, appropriateness and efficiency of the use of healthcare services, procedures and facilities under the provisions of the applicable health benefits plan in an effort to achieve desired clinical and financial outcomes.<BR><BR>Essential Duties: <BR>* <BR>Responsible for concurrent review of both inpatient and outpatient services in accordance with the utilization program which meets the requirements of The Joint Commission, Content Management System (CMS), Medical Staff Bylaws and third party payor contracts.<BR>* <BR>Facilitates the achievement of consistent clinical outcomes by concurrently assessing quality concerns and referring to appropriate individuals in accordance with FHS policy. Collects data and conducts focused reviews/studies.<BR>* <BR>Works collaboratively with the attending physician(s) to provide effective and efficient health care services that best serve the needs of the patient. Refers questionable cases regarding appropriateness of services to the attending physician and/or physician advisor.<BR>* <BR>Prepares and issues admission denials and decertification notices for termination of benefits in accordance with CMS, The Joint Commission and FHS standards.<BR>* <BR>Attends interdisciplinary discharge planning rounds and patient/family conferences as scheduled. Works pro-actively with Care Management team and the physician to facilitate the patient&#39;s discharge plan.<BR>* <BR>Collects data for interpretation and presentation to medical staff, hospital staff and administration.<BR>* <BR>Participates in continuing physician education and care management staff development activities. Serves as resource to physicians and hospital staff, as well as patients and their families, regarding quality and Utilization Management issues.<BR>* <BR>Provides data input to administration to assist in contract development and/or other programs as needed.<BR>* <BR>Represents care management services as a liaison to internal and external bodies. This includes, but is not limited to: Patient Access, Financial Account representatives, Regional Business Office, and third party payors.<BR>* <BR>Monitors third party payor denials with finance department and works with business office in preparing written responses to ensure optimum reimbursement.<BR><BR>Qualifications:<BR><BR>Education/Experience:<BR>* <BR><BR>Graduation from an accredited medical record technology/medical record administration program or any combination of experience and education that would demonstrate the capability to perform the duties of the position. Two (2) years of utilization or quality review in an acute care or outpatient setting including prior chart analysis experience required. <BR>License/Certification:<BR>* RHIT eligible or LPN/RN licensure require                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    </font></td>
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