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. Essential Functions and Responsibilities - 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. Job Requirements - 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. Knowledge, Skills & Abilities - 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