Job Description

About Us: At Sinai Chicago, we take health care personally. Excellence in healthcare is about more than just medicine, technology, tests, and treatments; it is about really caring for people with dignity and respect. That is what we do. We are dedicated to providing the best care to meet the needs of people, for our community, for our patients and for you. Position Purpose: Responsible for coordinating the Medical Record/Utilization Management Policies and Procedures according to standards set by Sinai Chicago Medical Staff, and outside regulatory agencies. This includes the analysis of medical records for documentation justifying the need for post-acute care services. This position works across the Sinai Chicago network of hospitals to provide insurance authorization services, and extended-stay reviews and recommendations to provide access to inpatient rehabilitation when appropriate. The Utilization Review/Reimbursement Specialist is responsible for driving denial management strategies to ensure all appropriate patients have access to inpatient programs. Key Job Activities: Coordinates utilization management review functions as set forth in the Hospital Utilization Review Plan (screening for determination of necessity, eligibility, and appropriateness) at preadmission, admission, continued stay and discharge. Analyzes insurance, governmental, and accrediting agency standards to determine criteria concerning admissions, treatment, and length of stay of patients. Manages the completion of prior authorization/recertification calls or faxes to a variety of third -party insurers as a part of the reimbursement process. Complex case reviews for determination of inpatient admission criteria. Implements strategies to navigate insurance authorization process efficiently. Responsible for robust data capture through documentation of denial management activities and outcomes. Assists manager in the following areas: Departmental and hospital-wide educational activities. Review and refinement of Utilization Review policies and procedures. Medical chart review and composition of insurance appeal letters on behalf of patients. Develops and maintains relationships with key payers to improve access to inpatient services. Admission office duties as assigned by the supervisor Education and Work Experience: Degree in nursing, social work, physical therapy, occupational therapy, speech therapy, athletic trainer, or equivalent degree A minimum of 2 years’ experience in Utilization Management Knowledge and Skills: Demonstrated competence in spelling, grammar, and composition and able to type accurately. Ability to interact with professional staff in an appropriate manner. Demonstrated competence in the use of a personal computer for development and use of appropriate Medical Records, Admissions, and Utilization Management applications. Experience in EPIC and MEDITECH software systems preferred. Certifications/Licenses: Valid driver’s license with no restrictions Certification as a Registered Health Information Technician or Registered Health Information Administrator a plus #J-18808-Ljbffr Sinai Health System

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