Mount Sinai Careers
Utilization Insurance Specialist - Mount Sinai West (Columbus Circle Area)
Strength Through Diversity
Ground breaking science. Advancing medicine. Healing made personal.
To provide clinical information to Managed Care/Insurance Companies/BHO to demonstrate medical necessity and ensure reimbursement.
- Responsible for all aspects of the concurrent review program, insurance certification, and authorization process for all Psychiatric or Chemical Dependency Inpatient Units (subject to assignment by management) and for all aspects of the initial review on an as needed basis
- Develops rapport with and daily working relations Admitting and Inpatient clinicians to insure ongoing, comprehensive clinical information if both documented and available in timely fashion to facilitate initial clinical reviews, pre-certifications and authorizations to admit to inpatient as well as continuing stay review approvals and authorizations
- Maintains daily communications and documentation with all Hospital Insurance Verification and Patient Accounts staff to insure timely verification of patient insurance and insurance status
- Coordinates insurance authorizations through provision of appropriate clinical information (confirmed by documentation) to insure optimization of inpatient authorizations. Develops ongoing relationships with insurance provider case managers to maximize authorization potential.
- Communicates with inpatient clinical staff to insure timely discharge planning is in place when insurance authorizations expire and patients become financially burdensome to the organization; seeking clinically appropriate alternatives from treating physicians, social workers, nursing staff.
- Monitors and coordinates the designation of alternative level of care with the UM Manager and/or Program Manager and Physician
- Notifies and coordinates inpatient services when delays are noted in order to reduce length of stay and improve quality of care
- Responsible for data and report generation of providers as well as regulatory agencies, as needed for Utilization Management activities
- Demonstrates the knowledge and skills necessary to provide care based on physical, psychosocial, educational, safety, and related criteria, appropriate to the age of the patient served in assigned area
- Utilizes Hospital Mainframe programs, CANOPY Care Management System, and TRAC effectively and coordinates updates with both Insurance Verification, Social Work management, and Patient Accounts as appropriate
- Refers appropriate cases to external agency (NCO) for second level of appeal.
- Prepares concurrent review information for Review/Appeals
- Meets time frame for reviews/appeals as specified by Insurance/State & Federal regulation
- Performs all aspects of the concurrent review program as well as initial pre-certification/authorization as needed to insure patient admission is approved
- Identifies and refers to the UM Manager &/or Administrator and/or Physician problematic utilization and quality issues
- Prioritizes work as per department protocol (IPRO Discharge Appeals / Insurance requests)
- Responsible for the maintenance of accurate data for approvals, denials and appeals (in coordination with UM Manager and management)
- Prioritizes insurance Request/Denials when received in the department as per protocol; Responds to Insurance requests for information to prevent denials/recover payment.
- Requests or provides Medical Records as required for appeals, On/Off-site Insurance reviews in both normal pursuit of regular UM activities.
- Obtains/Prepares Medical Records and other documentation for Photo Copying Service, outside 2nd party / Discharge Appeals in normal pursuit of regular UM activities.
- Assumes responsibility for Denial and Appeal processing and satisfaction as requested by UM Manager, or Departmental Manager
- In relationship to UM Insurance verification; authorizations and approvals; denials and appeals, will assist in the processing of mail
- Supervises support staff as needed.
- Includes meetings, education, training, coverage issues, annual evaluations.
- Responsible for maintaining good communication with direct supervisor and with all Clinical Directors and department administration.
- Responsible for maintaining a good working relationship with clinical and support staff on all levels.
- Responsible for creating effective relationships with other departments, as needed: Patient Accounts, Administration, Insurance Verification, Nursing, Utilization Management, Medical Records, Social Work, etc.
- Required to attend staff, departmental, divisional and hospital meetings as needed.
- Required to attend administrative, CQI, UM, High Risk, etc. meetings as needed.
- Orients new employees to department, division, and clinic administrative operations.
- Master’s Degree Preferred with experience in related field.
- Experienced in Insurance care management or utilization management.