**Job Description** 3034464: Utilization Insurance Specialist -Psychiatry Child Inpatient Unit -MSM- Full Time Day Job Summary: To provide clinical information to Managed Care/Insurance Companies/BHO to demonstrate medical necessity and ensure reimbursement. **Qualifications** + Master’s Degree Preferred with experience in related field. + Experienced in Insurance care management or utilization management. **Compensation Statement** The Mount Sinai Health System (MSHS) provides salary ranges that comply with the New York City Law on Salary Transparency in Job Advertisements. The salary range for the role is $65,885.00 - $98,827.00 Annually. Actual salaries depend on a variety of factors, including experience, education, and operational need. The salary range or contractual rate listed does not include bonuses/incentive, differential pay or other forms of compensation or benefits. Non-Bargaining Unit, BQC - Psychiatry Child Inpatient Unit - STL, Mount Sinai St. Luke's **Responsibilities** 1. Responsible for all aspects of the concurrent review program, insurance certification, and authorization process for all Psychiatric or Chemical Dependency Inpatient Units (subject to assignment by management) and for all aspects of the initial review on an as needed basis 2. Develops rapport with and daily working relations Admitting and Inpatient clinicians to insure ongoing, comprehensive clinical information if both documented and available in timely fashion to facilitate initial clinical reviews, pre-certifications and authorizations to admit to inpatient as well as continuing stay review approvals and authorizations 3. Maintains daily communications and documentation with all Hospital Insurance Verification and Patient Accounts staff to insure timely verification of patient insurance and insurance status 4. Coordinates insurance authorizations through provision of appropriate clinical information (confirmed by documentation) to insure optimization of inpatient authorizations. Develops ongoing relationships with insurance provider case managers to maximize authorization potential. 5. Communicates with inpatient clinical staff to insure timely discharge planning is in place when insurance authorizations expire and patients become financially burdensome to the organization; seeking clinically appropriate alternatives from treating physicians, social workers, nursing staff. 6. Monitors and coordinates the designation of alternative level of care with the UM Manager and/or Program Manager and Physician 7. Notifies and coordinates inpatient services when delays are noted in order to reduce length of stay and improve quality of care 8. Responsible for data and report generation of providers as well as regulatory agencies, as needed for Utilization Management activities 9. Demonstrates the knowledge and skills necessary to provide care based on physical, psychosocial, educational, safety, and related criteria, appropriate to the age of the patient served in assigned area 10. Utilizes Hospital Mainframe programs, CANOPY Care Management System, and TRAC effectively and coordinates updates with both Insurance Verification, Social Work management, and Patient Accounts as appropriate 11. Refers appropriate cases to external agency (NCO) for second level of appeal. 12. Prepares concurrent review information for Review/Appeals 13. Meets time frame for reviews/appeals as specified by Insurance/State & Federal regulation 14. Performs all aspects of the concurrent review program as well as initial pre-certification/authorization as needed to insure patient admission is approved 15. Identifies and refers to the UM Manager &/or Administrator and/or Physician problematic utilization and quality issues 16. Prioritizes work as per department protocol (IPRO Discharge Appeals / Insurance requests) 17. Responsible for the maintenance of accurate data for approvals, denials and appeals (in coordination with UM Manager and management) 18. Prioritizes insurance Request/Denials when received in the department as per protocol; Responds to Insurance requests for information to prevent denials/recover payment. 19. Requests or provides Medical Records as required for appeals, On/Off-site Insurance reviews in both normal pursuit of regular UM activities. 20. Obtains/Prepares Medical Records and other documentation for Photo Copying Service, outside 2nd party / Discharge Appeals in normal pursuit of regular UM activities. 21. Assumes responsibility for Denial and Appeal processing and satisfaction as requested by UM Manager, or Departmental Manager 22. In relationship to UM Insurance verification; authorizations and approvals; denials and appeals, will assist in the processing of mail 23. Supervises support staff as needed. 24. Includes meetings, education, training, coverage issues, annual evaluations. 25. Responsible for maintaining good communication with direct supervisor and with all Clinical Directors and department administration. 26. Responsible for maintaining a good working relationship with clinical and support staff on all levels. 27. Responsible for creating effective relationships with other departments, as needed: Patient Accounts, Administration, Insurance Verification, Nursing, Utilization Management, Medical Records, Social Work, etc. 28. Required to attend staff, departmental, divisional and hospital meetings as needed. 29. Required to attend administrative, CQI, UM, High Risk, etc. meetings as needed. 30. Orients new employees to department, division, and clinic administrative operations. **About Us** **Strength through Unity and Inclusion** The Mount Sinai Health System is committed to fostering an environment where everyone can contribute to excellence. We share a common dedication to delivering outstanding patient care. When you join us, you become part of Mount Sinai’s unparalleled legacy of achievement, education, and innovation as we work together to transform healthcare. We encourage all team members to actively participate in creating a culture that ensures fair access to opportunities, promotes inclusive practices, and supports the success of every individual. At Mount Sinai, our leaders are committed to fostering a workplace where all employees feel valued, respected, and empowered to grow. We strive to create an environment where collaboration, fairness, and continuous learning drive positive change, improving the well-being of our staff, patients, and organization. Our leaders are expected to challenge outdated practices, promote a culture of respect, and work toward meaningful improvements that enhance patient care and workplace experiences. We are dedicated to building a supportive and welcoming environment where everyone has the opportunity to thrive and advance professionally. Explore this opportunity and be part of the next chapter in our history. **About the Mount Sinai Health System:** Mount Sinai Health System is one of the largest academic medical systems in the New York metro area, with more than 48,000 employees working across eight hospitals, more than 400 outpatient practices, more than 300 labs, a school of nursing, and a leading school of medicine and graduate education. Mount Sinai advances health for all people, everywhere, by taking on the most complex health care challenges of our time — discovering and applying new scientific learning and knowledge; developing safer, more effective treatments; educating the next generation of medical leaders and innovators; and supporting local communities by delivering high-quality care to all who need it. Through the integration of its hospitals, labs, and schools, Mount Sinai offers comprehensive health care solutions from birth through geriatrics, leveraging innovative approaches such as artificial intelligence and informatics while keeping patients’ medical and emotional needs at the center of all treatment. The Health System includes more than 9,000 primary and specialty care physicians; 13 joint-venture outpatient surgery centers throughout the five boroughs of New York City, Westchester, Long Island, and Florida; and more than 30 affiliated community health centers. We are consistently ranked by U.S. News & World Report's Best Hospitals, receiving high "Honor Roll" status, and are highly ranked: No. 1 in Geriatrics, top 5 in Cardiology/Heart Surgery, and top 20 in Diabetes/Endocrinology, Gastroenterology/GI Surgery, Neurology/Neurosurgery, Orthopedics, Pulmonology/Lung Surgery, Rehabilitation, and Urology. New York Eye and Ear Infirmary of Mount Sinai is ranked No. 12 in Ophthalmology. U.S. News & World Report’s “Best Children’s Hospitals” ranks Mount Sinai Kravis Children's Hospital among the country’s best in several pediatric specialties. The Icahn School of Medicine at Mount Sinai is ranked No. 11 nationwide in National Institutes of Health funding and in the 99th percentile in research dollars per investigator according to the Association of American Medical Colleges. Newsweek’s “The World’s Best Smart Hospitals” ranks The Mount Sinai Hospital as No. 1 in New York and in the top five globally, and Mount Sinai Morningside in the top 20 globally. **Equal Opportunity Employer** The Mount Sinai Health System is an equal opportunity employer, complying with all applicable federal civil rights laws. We do not discriminate, exclude, or treat individuals differently based on race, color, national origin, age, religion, disability, sex, sexual orientation, gender, veteran status, or any other characteristic protected by law. We are deeply committed to fostering an environment where all faculty, staff, students, trainees, patients, visitors, and the communities we serve feel respected and supported. Our goal is to create a healthcare and learning institution that actively works to remove barriers, address challenges, and promote fairness in all aspects of our organization. **Compensation Statement** Mount Sinai Health System (MSHS) provides a salary range to comply with the New York City Law on Salary Transparency in Job Advertisements. The salary range for the role is $65885 - $98827 Annually. Actual salaries depend on a variety of factors, including experience, education, and hospital need. The salary range or contractual rate listed does not include bonuses/incentive, differential pay or other forms of compensation or benefits.