Utilization Review and Reimbursement Specialist

We have the great privilege of helping patients and families re-build their lives. It’s extraordinarily meaningful work and the reason we greet the day with optimism and anticipation. When patients “Ask for Mary,” they experience a culture that has been sculpted for more than a century. Our hallmark is to carefully listen to patients and innovatively serve them. This is true of every employee, from support staff and leadership to clinicians and care providers.   

Mary Free Bed is a not-for-profit, nationally accredited rehabilitation hospital serving thousands of children and adults each year through inpatient, outpatient, sub-acute rehabilitation, orthotics and prosthetics and home and community programs. With the most comprehensive rehabilitation services in Michigan and an exclusive focus on rehabilitation, Mary Free Bed physicians, nurses and therapists help our patients achieve outstanding clinical outcomes. The growing Mary Free Bed Network provides patients throughout the state with access to our unique standard of care 

Mission Statement  

Restoring hope and freedom through rehabilitation. 

Employment Value Proposition  

At Mary Free Bed, we take pride in our values-based culture: 

• Focus on Patient Care.  A selfless drive to serve and heal connects all MFB employees. 

• Clinical Variety and Challenge. An inter-disciplinary approach and a top team of professionals create ever-changing opportunities and activities. 

• Family Culture.  We offer the stability of a large organization while nurturing the family/team atmosphere of a small organization. 

• Trust in Each Other.  Each employee knows that co-workers can be trusted to make the right decision for our family, patients, staff, and community. 

• A Proud Tradition. Years of dedicated, quality service to our patients and community have yielded a reputation that fills our employees with pride.   

Summary  

​​Responsible for coordinating the Medical Record/Utilization Management Policies and Procedures according to standards set by the Hospital, Mary Free Bed 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 Mary Free Bed 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 Mary Free Bed inpatient programs.​ 

Essential Job Responsibilities  

• ​​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 at Mary Free Bed. 

• ​Admission office duties as assigned by the supervisor 

​Customer Service Responsibilities  

Demonstrate excellent customer service and standards of behaviors as well as encourages, coaches, and monitors the same in team members. This individual should consistently promote teamwork and direct communication with co-workers and deal discretely and sensitively with confidential information. 

Responsibilities in Quality Improvement  

Contribute by identifying problems and seeking solutions. Promote patient/family satisfaction where possible; participates in departmental efforts to monitor and report customer service. 

Essential Job Qualifications  

• Degree in nursing, social work, physical therapy, occupational therapy, speech therapy, or equivalent degree. 

• Valid driver’s license with no restrictions   

• 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.  

Preferred Job Qualifications 

• A minimum of 2 years’ experience in Utilization Management 

• Certification as a Registered Health Information Technician or Registered Health Information Administrator a plus 

Physical Requirements for Essential Job Qualification 

Levels: 

• None (No specific requirements) 

• Occasionally (Less than 1/3) 

• Frequently (1/3 to 2/3) 

• Majority (More than 2/3) 

Remain in a stationary position: ​Majority​ 

Traverse or move around work location: ​Occasionally​ 

Use keyboard:  ​Frequently​ 

Operate or use department specific equipment:  ​None​ 

Ascend/Descend equipment or ladder: ​None​ 

Position self to accomplish the Essential Functions of the role: ​None​ 

Receive and communicate information and ideas for understanding: ​None​ 

Transport, position, and/or exert force:  

Up to 10 pounds:   ​Occasionally​ 

Up to 25 pounds: ​ _____​ 

Up to 50 pounds: ​ _____​ 

Up to 75 pounds:  ​ _____​ 

More than 100 pounds: ​ _____​ 

Other weight: Up to___ pounds ​ _____​ 

       Other: ​None​