Utilization Review/Reimbursement Specialist
About Sinai Chicago
At Sinai Health System d/b/a Sinai Chicago, we take health care personally. Excellence in health care is about more than medicine, technology, tests, and treatments—it is about caring for people with dignity, compassion, and respect. We are committed to delivering exceptional care to our patients, supporting our communities, and creating meaningful career opportunities for our caregivers.
Position Summary
The Utilization Review/Reimbursement Specialist is responsible for coordinating Medical Record and Utilization Management activities in accordance with Sinai Chicago Medical Staff standards and applicable regulatory requirements. This role reviews medical records to determine the medical necessity and appropriateness of post-acute care services, secures insurance authorizations, conducts extended stay reviews, and supports patient access to inpatient rehabilitation services.
The specialist works collaboratively across the Sinai Chicago network to manage denial prevention and appeals, ensure timely payer approvals, optimize reimbursement, and promote access to the appropriate level of care.
Essential Job Responsibilities
Utilization Management & Authorization
- Coordinate utilization management review functions in accordance with the Hospital Utilization Review Plan, including:
- Preadmission reviews
- Admission reviews
- Continued stay reviews
- Discharge planning reviews
- Evaluate medical necessity, eligibility, appropriateness of care, and level-of-care determinations.
- Analyze insurance, governmental, and accreditation agency requirements related to admissions, treatment plans, and length of stay.
- Conduct complex case reviews to determine inpatient admission criteria.
- Manage prior authorizations, recertifications, and payer communications via phone, fax, or electronic platforms.
- Facilitate insurance approval processes to ensure appropriate patient access to inpatient rehabilitation services.
- Implement strategies to streamline authorization processes and minimize delays in care.
Reimbursement & Denial Management
- Develop and execute denial prevention and management strategies.
- Maintain thorough documentation of denial management activities, outcomes, and payer communications.
- Review medical records for reimbursement compliance and appeal opportunities.
- Draft and coordinate insurance appeal letters and supporting documentation on behalf of patients.
- Assist in maximizing reimbursement while maintaining compliance with payer requirements and clinical standards.
Departmental Support
- Support departmental and organization-wide educational initiatives.
- Assist with reviewing, updating, and improving utilization review policies and procedures.
- Develop and maintain positive working relationships with insurance payers and referral sources.
- Perform admission office responsibilities as assigned by leadership.
- Participate in special projects and other duties as assigned.
Diversity, Equity, Inclusion, and Belonging
The Utilization Review/Reimbursement Specialist is expected to promote Sinai Chicago’s commitment to Diversity, Equity, and Inclusion by:
- Treating all individuals with dignity and respect.
- Supporting opportunities for underrepresented communities.
- Encouraging talent development and growth.
- Identifying and helping eliminate disparities.
- Taking action against bias, racism, and injustice.
- Honoring differences and fostering collaboration.
- Educating staff, patients, and community members.
- Supporting the mission of restoring hope and freedom for all.
Customer Service Expectations
- Demonstrate exceptional customer service and professional behavior.
- Promote teamwork, collaboration, and effective communication.
- Maintain confidentiality and discretion when handling sensitive information.
- Foster positive relationships with patients, families, colleagues, physicians, and external partners.
- Serve as a role model for outstanding customer service and organizational values.
Quality Improvement Responsibilities
- Identify opportunities for process improvement and operational efficiency.
- Participate in departmental quality initiatives and performance improvement activities.
- Support efforts to monitor and improve patient and family satisfaction.
- Report issues and recommend solutions that enhance patient outcomes and service quality.
- Perform additional duties as assigned.
Education & Experience
Required
- Bachelor’s degree or equivalent professional degree in one of the following disciplines:
- Nursing
- Social Work
- Physical Therapy
- Occupational Therapy
- Speech Therapy
- Athletic Training
- Related healthcare field
- Minimum of 2 years of Utilization Management experience.
Preferred
- Experience in post-acute care, rehabilitation services, or care coordination.
- Experience working with managed care organizations and third-party payers.
Knowledge, Skills & Abilities
- Strong understanding of utilization review principles, reimbursement practices, and medical necessity criteria.
- Excellent written and verbal communication skills.
- Demonstrated proficiency in spelling, grammar, and professional correspondence.
- Ability to effectively collaborate with physicians, clinicians, and administrative staff.
- Strong analytical and problem-solving skills.
- Proficiency with personal computers and healthcare information systems.
- Experience with:
- EPIC (preferred)
- MEDITECH (preferred)
- Ability to manage multiple priorities in a fast-paced healthcare environment.
Licenses & Certifications
Required
- Valid driver's license with no restrictions.
Preferred
- Registered Health Information Technician (RHIT)
- Registered Health Information Administrator (RHIA)
Benefits
Sinai Chicago offers a competitive and comprehensive benefits package, which may include:
- Medical, Dental, and Vision Insurance
- Prescription Drug Coverage
- Employer-Paid Life Insurance and AD&D
- Supplemental Life Insurance
- Short-Term and Long-Term Disability
- Health Savings Account (HSA)
- Flexible Spending Account (FSA)
- Employee Assistance Program (EAP)
- Student Loan Assistance Program
- 403(b) Retirement Savings Plan
- Paid Leave Programs
Eligibility for certain benefits is based on scheduled hours worked and completion of applicable waiting periods.
Sinai Chicago Values
All caregivers are expected to demonstrate the following values:
Teamwork
Collaborates effectively to create an inclusive and supportive workplace.
Respect
Treats all individuals with dignity, fairness, and appreciation.
Quality
Strives for excellence through continuous improvement and adherence to best practices.
Integrity
Demonstrates honesty, accountability, and ethical behavior.
Safety
Promotes and maintains a safe environment for patients, visitors, and colleagues.
Role Model
Serves as a dependable representative of Sinai Chicago's mission and values.
Sinai Chicago is an Equal Opportunity Employer committed to fostering a diverse, equitable, and inclusive workplace.
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