LEAD UTILIZATION SPECIALIST -RN

Under the guidance of the Case Manager, the Lead Utilization Specialist serves as a resource for internal and external customers dealing with third-party payors, including Medicare and Medicaid.

Principal Duties and Responsibilities (Essential Functions):

• Advises relevant departments on current regulations applicable to private payors, as well as Federal and State requirements.
• Assists hospital attorneys with court cases through chart reviews and communication.
• Coordinates responses to the Peer Review Organization concerning medical and hospital issues.
• Appeals denied hospital cases to the appropriate third-party payor.
• Provides outcome data, such as the number of appeals, and confirms quality issues through data entry.
• Defines and interprets hospital policies in relation to government regulations as needed.
• Communicates, both verbally and in writing, with internal and external customers regarding reimbursement and regulatory issues.

Job Specifications (Minimum Requirements):

• Demonstrates excellent customer service skills and responds positively to patient and family needs.
• Knowledge of government regulations affecting hospital operations.
• Knowledge of Diagnosis Related Group (DRG) coding to assist the Utilization Specialist.
• Excellent verbal and written communication skills.
• Strong interpersonal and problem-solving skills for negotiating sensitive issues.
• Proficient in extracting relevant data from medical records to appeal denied cases.
• Ability to analyze data and develop action plans accordingly.
• Ability to interpret complex medical and publication materials related to customer issues.

Education:

• Bachelor's Degree in Nursing required.
• Six years of RN experience required; licensed Registered Nurse.
• Certified in Cardiac Pulmonary Resuscitation.

Standards of Behavior: Meets the Standards outlined in Personnel Policy and Procedure , Employee Relations Code. Confidentiality/HIPAA/Corporate Compliance: Demonstrates knowledge of procedures to maintain the security, confidentiality, and integrity of all medical and organizational information. Supports Methodist Hospitals' commitment to adhering to applicable laws and regulations governing ethical healthcare practices.

Disclaimer: The above statements describe the general nature and level of work performed by individuals in this role and are not exhaustive of all responsibilities, duties, or skills required.