Utilization Review Specialist

The incumbent functions as a Utilization Review Specialist in Health Information Management. The Utilization Review Specialist performs studies/reviews of medical records to monitor and to determine that the quality of clients’ treatment and care are maintained at the highest level. Examines and evaluates various components of client’s medical records to bill for Medicare reimbursement and commercial insurance for about 92 to 105 clients with insurance. These numbers may vary from month to month. When assessing the documentation, adheres to the policies and various guidelines, set by internal and external bodies, such CMS and JACHO. Attends treatment plan meetings, when necessary, in order to get collateral information from family members and case managers, to forward to commercial insurance companies. The incumbent is responsible for providing feedback to Utilization Review Committees, clinicians, clinical staff of various disciplines and Directors concerning the development and refinement of quality care criteria. Provides individual case discussions with attending clinicians and multidiscipline staff members to attain clarifications, to render recommendations, to tactfully persuade and negotiate oppositions and to facilitate acceptance of recommendations and modifications. Identifies problems, trends, and deficiencies, and factors requiring examination, evaluation and/or resolution as a result of reviewing various clinical documentations, data, methods and procedures related to admissions, continued hospitalization, treatment and care. Collects information and statistical data for compiling monthly reports which identify trends, problems, recommendations, achievements, resolutions and areas of high and low compliance. Submits annual written reports, consisting of statistical and graphic data, complied from the variety of studies performed in each division during the year. Distributes Level of Care Survey Forms each month to designated clinical staff member for completion and is responsible for attaining necessary corrections on forms returned with errors. Serves as liaison and resource person responsible for establishing and maintaining effective interactive communication and cooperation between the clinicians, multi-discipline clinical staff members and divisions’ Utilization Review Committees/Quality Assessment Committees. Adapts studies to stay in line with changing criteria and formats. Responsible for making recommendations, which have SEH-wide affect to clinicians, clinical staff of various disciplines and division directors regarding criteria compliance issues. Prioritizes reviews to ensure that wards are visited during convenient and appropriate times.

RESIDENCY PREFERENCE AMENDMENT ACT OF 1988

A person applying for a position in the Career Service, Educational Service, Management Supervisory Service, a line attorney position in the Legal Service (series 905), or an attorney position in the Excepted Service (series 905) who is a bona fide District resident AT THE TIME OF APPLICATION for the position may be awarded a 10-point residency preference over non-District applicants, unless the person declines the preference points. If selected, the person shall be required to present no less than 8 proofs of bona fide District residency and maintain such residency for 7 consecutive years from the effective date of the appointment. Failure to maintain bona fide District residency for the 7-year period will result in forfeiture of employment.

This position IS in a collective bargaining unit and you may be required to pay an agency service fee through an automatic payroll deduction

Position Designation: This position is deemed as “Security Sensitive” pursuant to Section 410 of Chapter 4 of the D.C. Personnel Regulations, in addition to the general suitability screening, individuals applying for or occupying security sensitive positions are subject to the following checks and tests:

Area of Consideration: Open to the Public

Duration of Appointment: Permanent

First Screening: April 8, 2024.

Tour of Duty: 8:30 a.m. - 5:00 p.m. Monday to Friday

Work Experience

Advanced knowledge of mental health concepts, principles, practices, programs and operations based on professional training in health care methodologies. Detailed knowledge of techniques for record review methods, evaluation of clinical documentation and clinical interventions in the medical records review. Ability to work in a team environment and assist others such as third parties in understanding documentation requirements

Qualifications

In addition to meeting the basic requirements, this position requires one (1) year of experience equivalent to the next lower grade level equivalent to DS-11.

Education

Candidates must have completed four (4) years course of study in an accredited college or university. Bachelors or higher degree with major study in an academic field related to health or allied sciences pertinent to this position.

Selective Placement Factor:

Bachelor’s Degree in Nursing preferred.

Work Environment

Work is performed in a controlled environment and involves some exposure to moderate risk of accidents and requires following basic safety precautions. THIS POSITION REQUIRES A PRE EMPLOYMENT PHYSICAL, CONSUMER CREDIT CHECK & DRUG TEST.

COVID-19 Vaccination

The Government of the District of Columbia values the safety of our employees, our residents, and our visitors. In support of these values, if you are selected for this job you must be fully vaccinated against COVID-19, except when vaccination is not medically advised or violates your sincerely held religious beliefs in violation of EEO laws. If you are invited to join our team you must submit proof that you are fully vaccinated against COVID-19 to your initial HR representative, or you must request an exemption from your representative. New employees must either provide proof of vaccination or be granted a medical or religious exemption before working with the Government of the District of Columbia.

EEO Statement: The District of Columbia Government is an Equal Opportunity Employer. All qualified candidates will receive consideration without regard to race, color, religion, national origin, sex, age, marital status, personal appearance, sexual orientation, family responsibilities, matriculation, physical handicap, or political affiliation.

Job Offers: Official Job Offers are made by the office of Human Resources Only.