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The Utilization Review Specialist interacts with customers in a caring and respectful manner in accordance with Eskenazi Health Core Values. The Specialist acts as a patient information liaison and interfaces with Transitional Support staff, providers and specialists to assist in problem-solving. 

   Proactively contributes to Eskenazi Health's mission: Advocate, Care, Teach and Serve with special emphasis on the vulnerable population of Marion County. Models Eskenazi's values of Professionalism, Respect, Innovation, Development and Excellence. 
   Interacts with all internal and external customers in a caring and respectful manner in accordance with Eskenazi Health Core Values.
   Performs pre-certification activities related to inpatient services in accordance with predetermined departmental criteria.
   Interfaces with Pharmacy and Specialty Clinic staff to initiate authorization of biological and neoadjuvant medications. 
   Maintains timeliness of payor communication in regard to notification of admission, appeals , and retro-authorizations. 
   Determines validity of coverage following established authorization requirements and refers to the inpatient discharge planner and inpatient Financial Counseling teams for further determinations of coverage, as needed.
   Communicates and negotiates with payers to obtain approvals for the appropriate care level 
   Maintains open collaborative active communication with the Utilization Review nurses' team to ensure timely patient progression through the episode/plan of care
   Documents and maintains pre-certification/authorization information accessible by the healthcare system
   Responsible for maintaining denial management processes in collaboration with UR Nurses, physicians, revenue cycle, and business partners. 
   Responsible for maintaining knowledge of provider manuals and payor practices regarding inpatient authorizations, denial management, and retro-authorizations
   Research and responds provider inquires concerning unauthorized claims 
   Provides direct support to providers regarding utilization review and authorization.
   Operates within program requirements in accordance with CMS standards.

   High school diploma or General Equivalency Diploma (GED)
   2 years of experience in a healthcare related authorization required
   Medicaid, Medicare, and Commercial experience required
   Knowledge of computer and related software
   Ability to discern numbers and names, paying specific attention to detail to ensure accuracy in data entry
   Works as an effective team member
   Knowledge of general office procedures and mandated retention periods for pre-services
   Proficiency in document imaging processes, oral and written communications, customer service, and organization

   Self-starter with strong analytical and organizational skills, and ability to work independently and under minimal direction/supervision
   Demonstrates professional telephone etiquette, strong written and verbal communication skills, and ability to work collaboratively with others (both intra and interdepartmentally) 
   Ability to perform clerical functions in a health care setting
   Proficiency in basic and intermediate word processing (MS Word and Office)
   Proficiency in spreadsheet applications, reporting skills, managing processes, supply management, inventory control
   Ability to determine member benefit coverage via Indiana Medicaid Portal, Atrezzo, Availity, and UHC Link, Cohere, Optum, VA, and other payor platforms. 
   Ability to provide direct support to providers regarding utilization, authorization, and referral activities
   Knowledge of office procedures and Utilization Management Policies
   Team player, verbal and written communication skills, ability to collaborate with the interdisciplinary medical staff, excellent telephone and reception skills, and able to work flexible hours
   Ability to use age appropriate communication skills
   Knowledge of Hospital policies and procedures, general office procedures, correct English grammar/punctuation/spelling and aptitude for basic mathematical functions
   Responsible for maintaining knowledge of provider manuals and payor practices regarding authorizations, denial management, and retro-authorizations
   Demonstrates a general understanding and use of Medical and Insurance terminology
   Ability to prioritize workload/schedules and perform duties without direct supervision
   Attention to detail and complete work with high rate of accuracy
   Flexibility to changing departmental requirements
   Ability to coordinate and organize multiple tasks and projects at once
   Functions effectively under pressure of deadlines and work volume
   Knowledge of medical terminology preferred