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Utilization Insurance Specialist

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Mount Sinai Health System

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Location:
United States , New York

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Category:
Insurance

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Contract Type:
Not provided

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Salary:

65885.00 - 98827.00 USD / Year
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Job Description:

To provide clinical information to Managed Care/Insurance Companies/BHO to demonstrate medical necessity and ensure reimbursement.

Job Responsibility:

  • Responsible for all aspects of the concurrent review program, insurance certification, and authorization process for all Psychiatric or Chemical Dependency Inpatient Units
  • Develops rapport with and daily working relations Admitting and Inpatient clinicians to insure ongoing, comprehensive clinical information
  • 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
  • Communicates with inpatient clinical staff to insure timely discharge planning is in place when insurance authorizations expire
  • 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
  • Demonstrates the knowledge and skills necessary to provide care based on physical, psychosocial, educational, safety, and related criteria
  • Utilizes Hospital Mainframe programs, CANOPY Care Management System, and TRAC effectively
  • 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
  • Identifies and refers to the UM Manager &/or Administrator and/or Physician problematic utilization and quality issues
  • Prioritizes work as per department protocol
  • Responsible for the maintenance of accurate data for approvals, denials and appeals
  • Prioritizes insurance Request/Denials when received in the department as per protocol
  • Requests or provides Medical Records as required for appeals
  • Obtains/Prepares Medical Records and other documentation for Photo Copying Service
  • Assumes responsibility for Denial and Appeal processing and satisfaction
  • In relationship to UM Insurance verification
  • authorizations and approvals
  • denials and appeals, will assist in the processing of mail
  • Supervises support staff as needed
  • 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
  • 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

Requirements:

  • Master’s Degree Preferred with experience in related field
  • Experienced in Insurance care management or utilization management

Additional Information:

Job Posted:
February 14, 2026

Employment Type:
Fulltime
Work Type:
On-site work
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