Covenant Health

Job Title
UTIL MGMT SPECIALIST I
ID
3155125
Facility
Covenant Health Corporate
Department Name
REV INTEGRITY & UTIL

Overview

Covenant Health

Utilization Management Specialist

Part Time, 48 hours per pay period; Day shift (hours/days may vary based on need). 

 

Covenant Health Overview:

Covenant Health is East Tennessee’s top-performing healthcare network with 10 hospitals and over 85 outpatient and specialty services, and Covenant Medical Group, our area’s fastest-growing physician practice division. Headquartered in Knoxville, Covenant Health is a community-owned, not-for-profit healthcare system and the area’s largest employer with over 11,000 employees.

 

Covenant Health is the only healthcare system in East Tennessee to be named six times by Forbes as a Best Employer. 

 

Position Summary:

The Utilization Management Specialist I will perform utilization management functions to include medical necessity reviews to promote a utilization management program. The UM Specialist prepares and reviews necessary documentation for insurance utilization management processes and coordinates communication between members of the UM team to ensure timely follow through for status placement.  The UM Specialist collaborates with attending physician if ambiguous documentation pertaining to patient status placement requires clarification. The UM Specialist utilizes electronic utilization management database for documentation of interventions and communications so as to ensure accurate reporting.  Collaborates with patient account services, physicians, care coordinators, physician advisors and facility departments as related to utilization management. Communicates with hospital and payor medical directors in order to correctly determine the medical necessity of patient status with a patient advocacy focus.

 

Responsibilities

  • Reviews providers’ requests for services and coordinates utilization management review.
  • Reviews precertification requests for medical necessity for all payors as applicable, referring to the second level physician reviewer those that require additional expertise.
  • Maintains accurate records of all communications and interventions related to utilization management.
  • Sets up communications with payors and/or physicians as applicable.
  • Collaborates with payor utilization management liaisons and medical directors as applicable.
  • Reviews all cases received from the registration department to verify that the insurance pre-certification process has been completed in order to meet contractual obligations.
  • Coordinates execution of notices (denials) of non-coverage when appropriate and communicates with key stakeholders to ensure that patient liability is correctly managed.
  • Intervenes in Peer-to-Peer meetings between physicians and payors as applicable.
  • Exhibits effective verbal and written communication skills in order to clearly present clinical and financial data to various audiences as necessary.
  • Completes daily work lists for utilization review meeting the time frames set forth by Covenant Health.

 

Qualifications

Minimum Education: None specified; will accept any combination of formal education and/or prior work experience sufficient to demonstrate possession of the knowledge, skill and ability needed to perform the essential tasks of the job, typically such as would be equivalent to a high school diploma or GED.  Preference may be given to individuals possessing a HS diploma or GED.

 

Minimum Experience: At least two (2) years of utilization management, case management or equivalent experience

 

Licensure Requirements: Current Tennessee LPN license is preferred

Apply/Share

Sorry the Share function is not working properly at this moment. Please refresh the page and try again later.
Share on your newsfeed