CARE TRANSITION SPECIALIST - UTILIZATION MANAGEMENT / PER DIEM/ ROTATING - BWH CARE COORDINATION
Brigham & Women's Hospital(BWH)

Boston, Massachusetts


General Summary/Overview

The UM Care Transition Specialist (UM CTS) acts as a resourceto the Care Continuum Team (CCT), medical staff, nursing staff, finance,Patient Access and other hospital departments to clarify regulatory rules andrequirements of all third-party payers. Supports the clinical work of InsuranceSupport (ISN), Care Coordinator RNs and the clinical denials' processes. UM CTS acts as a liaison between internalstaff and external payers. UM CTS maintainsand monitors the reporting of utilization management functions.

Principle Duties and Responsibilities

ResourceManagement

  • UM CTS screens telephone and telefax requests. Responds to inquiries and makes appropriate referrals. Inputs essential data from third party payers into the EHR and other hospital software, resolves inconsistencies at all times. UM CTS monitors financial information for accuracy. UM CTS responds to and provides documentation to payers.


  • UM CTS works closely with finance to resolve reimbursement issues; with outpatient care coordinators, admitting, medical records, medical staff and other departments to identify problem areas and develop strategies to resolve them.


  • UM CTS develops strong working relationships with public and private agencies to assure that all available resources are pursued to finance patient care costs during and after the in-hospital stay.


  • UM CTS coordinates Utilization Management information for the Medical Directors, Practice site meetings and Utilization Review Committee meetings.


  • UM CTS communicates with health plans and others to monitor approval, verify eligibility and authorization process with contracted vendors and agencies.


  • UM CTS inputs authorizations into system as directed by the team


  • UM CTS under UM direction enters referral/auth numbers into computer systems.


  • UM CTS communicates with internal hospital departments such as Admitting, Managed Care Department, other Care Coordination teams to facilitate timely approval processes and data integrity.


  • UM CTS verifies information on internal reports (census, referral reports, admitting reports) and distributes to appropriate Care Coordinator.


  • UM CTS refers eligibility issues and edits to dictionary of preferred providers. Assists with edits in registration/dictionary when authorization communications are time sensitive and dependent on accurate dictionary information.


  • UM CTS participates in quality improvement activities.


  • UM CTS cross covers for other CTSs in the team and occasionally in other areas of the department


  • Denial Management

  • UM CTS facilitates cases (cited by third party payers) appropriate for appellate process. This role provides assistance and data to the health care team in overturning initial denial decisions by third party payers.


  • UM CTS Manages all functions relating to quality citation, admission and continued stay denials issues from private contracted, federal and state agencies.


  • UM CTS participates in retrospective medical reviews for contract payers, hospital accounts receivable and admitting departments with regard to denials/pending claims.


  • UM CTS initiates and tracks correspondence between the hospital staff and agencies. Monitors and maintains the denial data base to track specific information for physician, service and denial types.


  • UM CTS assists and advises medical staff and the Care Coordination Staff in understanding regulatory requirements and advises the medical staff in writing appeal responses.


  • UM CTS maintains and monitors several record keeping systems. Solely maintains records and files containing complex and/or extremely sensitive material such as specific physician quality of care issues.


  • Communicates to the Care Continuum Team, third party nurse reviews and the hospital community issues relating to pends/denials.


  • Regulatory Management

  • UM CTS facilitates and monitors state government programs to assure compliance with strict regulatory guidelines.


  • UM CTS obtains and processes screening numbers for approved patients to facilitate payment from state government payers.


  • Working hours could be:

    8a to 4:30; 8:30 a to 5

    Qualifications
    • High School Degree or GED required
    • Bachelors' degree preferred
    • Requires medical terminology
    • Requires proven outstanding communication, customer service and organization skills
    • Requires experience in a health care setting
    • Experience in Utilization Review, Patient Access or Claim management preferred

    SKILLS/ ABILITIES/ COMPETENCIES REQUIRED:

    • Excellent communication and organizational skills
    • Orientation to detail to insure accuracy a must
    • Computer literacy, windows operating system, word processing, spreadsheet, database management
    • Knowledge of medical terminology, managed care concepts and community organizations.
    • An independent yet team oriented person is crucial for care coordination process.
    • Strong analytical skills
    • Ability to work in a fast paced environment and to constantly change priorities
    • Ability to maintain a high degree of confidentiality
    • Strong interpersonal skills; must work closely and cooperatively with physicians and other health care professionals
    • Ability to work independently, make decisions, and to exercise appropriate judgment in setting priorities
    • Familiarity with Microsoft Word, Excel and Access is a plus

    WORKING CONDITIONS:

    Works in a busy and, at times, stressful hospital/office environment. Must be able to work well independently and in a multi-disciplinary group. Must be flexible.

    EEO Statement
    Brigham and Women's Hospital is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, creed, sex, sexual orientation, gender identity, national origin, ancestry, age, veteran status, disability unrelated to job requirements, genetic information, military service, or other protected status.



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