Utilization Review Specialist

Colorado Springs, CO
United States

Experience Required
Employment Type
Work Schedule

Job Description
POSITION SUMMARY: The Utilization Review Specialist is responsible for establishing and maintaining utilization review (UR) and utilization management (UM) for Rocky Mountain Health Care Service (RMHCS) participants. A successful Utilization Review Specialist will have a strong foundation in established medical criteria and benefits coverage criteria as it relates to reviewing service requests for various products and services provided by RMHCS. This position has a high level of interaction with providers as well as the Chief Medical Officer in the approval and/or denial processes, so advanced relationship management skills as well as clinical and technical expertise is required.

MISSION: Improving lives, Optimizing wellness, Promoting independence

  • Communication
  • Consultation
  • Customer Service/Participant Focus
  • Critical Evaluation
  • Ethical Practice
  • Relationship Management
  • Stress Management/Composure
  • Technical Capacity

  • Reviews requests for services and procedures written by providers that require medical necessity review, benefit interpretation and utilization management analysis. Examples of services include, but are not limited to, elective surgery (inpatient and outpatient), Durable Medical Equipment, home care, therapy services, and IV infusions.
  • Consults directly with the Chief Medical Officer for requests that do not meet medical/coverage criteria and/or utilization requirements. Gathers more information from providers or informs providers of the Chief Medical Officers determination on eligibility, as appropriate.
  • Makes first level approvals determinations for services on medical appropriateness and benefit coverage and consults with the Chief Medical Officer and Quality Compliance Officer as requested.
  • Acts as a subject matter expert for medical and benefit coverage criteria, the policies and processes they relate to, and the consistent implementation of criteria across procedural practices established by RMHC Quality team.
  • Acts as an intermediary between the Clinical, Quality, Finance, and other relevant departments in the development and implementation of protocols to standardize care delivery.
  • Assists the Quality and Compliance Officer in establishing, reviewing and compliance with UM policies and procedures.
  • Performs and active role in the interdisciplinary team (IDT) including facilitation of meetings, information validation and helping in the decision making process in regards to care delivery.
  • Creates and sends denial letters to members/providers as stipulated within established timeframes.
  • Communicates with participants regarding service determinations outcomes as required by state, federal and other accreditation requirements.
  • Serves as a clinical resource for referrals, as requested by the Clinical Team.
  • Designs and implements training programs in conjunction with HR training team for internal/external customers regarding appropriate medical services, care delivery determination process, financial impacts of service determination, utilization analysis/review/etc.
  • Maintains thorough understanding of Medicaid/Medicare guidelines and regulations and applies knowledge to ensure we are providing adequate and compliant care and products.
  • Adheres to all regulatory timeframes and internal standards for documentation of the precertification and utilization/benefit management program to ensure compliant, consistent communication with all internal/external customers.
  • Provides excellent documentation management in order to justify all decisions regarding service determinations.
  • Other duties as assigned
  • Demonstrates support of the Companys Mission, Vision and Core Values
  • Provides Exceptional Customer Service
  • Ensures discretion with confidential information in accordance with HIPAA guidelines
  • Supports a collaborative work environment including courteous, helpful and professional behavior
  • Embraces Organizational Excellence through practicing individual time management, efficiency and effectiveness and participating in continuous improvement efforts
  • Adheres to and supports all Company policies and procedures
  • Supports and practices safe work habits in accordance with policies and procedures
  • Brings ideas, problems and concerns forward and participates in resolution and implementation
  • Participates in and completes regulatory compliance trainings within the prescribed deadlines
  • Attends required meetings
  • Maintains skills and knowledge required including written and verbal communication, best practices for industry standards, and computer competency