System Utilization Management Specialist + Oakland, CA + Highland General Hospital + SYS Utilization Management + Full Time - Day + Care Management + Req #:40970-30273 + FTE:1 + Posted:December 20, 2024 **Summary** **SUMMARY:** Supports our Utilization Management Team for all inpatient facilities enhancing operational efficiency and patient care coordination. Key responsibilities include reconciling patient census data, providing administrative assistance, facilitating discharge planning, liaising with payors, and ensuring precise data entry and reporting. This role demands accuracy and the ability to manage multiple tasks effectively, supporting both clinical and administrative functions within the department. **DUTIES & ESSENTIAL JOB FUNCTIONS:** NOTE: The following are the duties performed by employees in this classification. However, employees may perform other related duties at an equivalent level. Not all duties listed are necessarily performed by each individual in the classification. 1. Collaborates with Utilization Management staff to provide specific clinical information for the purpose of completing initial and concurrent utilization review to ensure certification/approval of in-patient and post discharge services as delegated by the care coordination nursing staff at all AHS acute care facilities. 2. Communicates status with Utilization Management staff and arranges for patient transfer; functions as a key point of contact between Utilization Management staff, admissions and payers. 3. Coordinate and track any communication, e.g. Important Message (IM) letters, Denial Letters, patient choice forms; regularly updates Utilization Management team. 4. Coordinates and obtains authorizations for admissions; documents all information in the AHS financial system; works closely with Revenue Cycle to ensure each inpatient encounter is accurate; coordinates all reviews and inquires with the payors. 5. Coordinates with referral sources on bed availability, new product and services; maintains current database of existing and potential referral sources. 6. Functions as a key point of contact between clinical Utilization management staff, admissions and payors. Documents all interactions with payors and communicates status with Utilization Management staff. 7. Manages multiple inquiries and presents referrals based on location and services provided; provides appropriate follow up on active or pending inquires as delegated by the care coordination nursing staff. 8. Per the direction and delegation of the Utilization Management social worker and/or nurse, facilitates, identifies and documents all referrals made to contracted facilities, providers or agencies, makes post discharge appointments for patients and coordinates transportation; expedites discharges by transmitting appropriate documentation to providers for acceptance of patient; documents all interactions with payers and communicates status with appropriate staff and evidences activities in the patient’s medical record. 9. Perform all other duties as assigned. 10. Reconciles census; works with Patient Access and the Utilization Management team to ensure census is correct in the financial and Utilization management systems; prepares paperwork and updates encounter information for admissions, discharges and transfers of patients; prepares census for the Utilization Management staff. 11. Confirms that copies of regulatory compliance documents provided to patients/ family members as delegated by the UM Nursing Team are in the EMR. 12. Supports any audits with coordinating medical records with HIM; prepares statements of diagnosis and treatments, and extracts other information required for the completion of forms received from patients’ insurance carriers. **MINIMUM QUALIFICATIONS:** Preferred Education: Bachelor’s degree in related field. Preferred Experience: Medical Assistant. Required Education: High school diploma or G.E.D. Required Experience: Three years in a health Case field or one year in Utilization Management or Case Management at a Medical Group, Acute Care Environment or Health plan experience; electronic Health Record (EHR) and Utilization Management applications, e.g. EPIC, Midas or 3M. Alameda Health System is an equal opportunity employer and does not discriminate against any employee or applicant for employment based on race, color, religion, national origin, age, gender, sex, ancestry, citizenship status, mental or physical disability, genetic information, sexual orientation, veteran status, or military background.