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Sr. Resource Specialist

  • Job ID: 190001IS
  • Status: Full-Time
  • Regular/Temporary: Regular
  • Hours: 8 a.m. to 4:30 p.m.
  • Shift: Day Job
  • Facility: UPMC Pinnacle Hospitals
  • Department: Outcomes Management
  • Location: 111 South Front Street, Harrisburg PA 17105
  • Union Position: No
  • Salary Range: $21.26 to $31.88 / hour

Description

Purpose:
Is responsible for coordinating complex services for patients through the placement request process and facilitates medical necessity review through timely communication of clinical information to third party payers to ensure certification, approval and authorization of inpatient and post discharge services according to established guidelines. This individual coordinates and facilitates the psychiatric placement and authorization process and serves as a knowledgeable resource to interpret, facilitate and meet timelines associated with third party payers, state, and federal agencies with discharge planning and medical necessity authorization processes. 

Join an organization that cares! UPMC is searching for a Sr. Resource Specialist to join our Outcomes Management team.

Responsibilities:
  • Effectively communicates clinical information and negotiates with payors in collaboration with the Outcomes Management staff to obtain authorization for appropriate level of care and length of stay and documents interactions in information system.
  • Provides prompt feedback regarding payor determinations to Outcomes Management staff, enabling them to evaluate/re-direct the current patient plan of care in order to streamline the delivery of service.
  • Works collaboratively with physicians, office staff, clinic and Outcomes Management personnel in order to facilitate accurate and timely authorizations.
  • Reviews registration change requests and observation status reports and evaluates if clinical criteria is met per medical necessity standards.
  • Works effectively in a team effort. Acts as a liaison to share patient-specific insurance and updates to pertinent areas.
  • Negotiates concurrent denials and communicates findings to the Case Manager or Outcomes Manager.
  • Works collaboratively with the business office and insurance companies to resolve payment errors or discrepancies to maximize reimbursement.
  • Responsible for correspondence and follow-up related to placement, third party payer authorizations and service coordination. Coordinates transportation requirements for psychiatric placement with the ambulance companies, patient care services and outcomes management. Communicates clinical and psychological status to insurance companies to obtain authorization for psychiatric services. Obtain Durable Medical Equipment, transportation or other post-acute services as identified from the Outcomes Management staff.
  • Facilitates authorization status decisions and complex discharge planning based on established medical necessity criteria, objective findings and contractual requirements.
  • Identifies concurrent denials by third party payors and notifies Outcomes Management staff for immediate intervention and may recommend solutions.
  • Acts in a leadership role within the department through supervises staff to ensure completion of tasks and productivity and adjust workload as indicated. Is responsible for daily operations in absence of Manager. Participates in staff education, orientation, and development of action plans. 

Qualifications

  • LPN licensure or BSW required.
  • Licensed Practical Nurse (LPN) preferred.
  • Two to three years experience in a health care setting.
  • Knowledge of third party reimbursement or resource utilization required plus strong clinical background.
  • Experience with office machines (i.e. copier, fax, and telephone) computer terminal/personal computer, software (i.e. word processing, spreadsheets, etc.)

Licensure, Certifications, and Clearances:
  • Act 33 with renewal
  • Act 34 with renewal
  • Act 73 FBI Clearance with renewal

  • UPMC is an equal opportunity employer. Minority/Females/Veterans/Individuals with Disabilities

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       Current UPMC employees must apply in HR Direct

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