PRN Utilization Specialist

East Tennessee Behavioral Health • Knoxville, TN

2d

About The Position

The PRN Utilization Specialist proactively monitors utilization of services for patients to optimize reimbursement for the facility. The role serves as a liaison between managed care organizations and facility clinical staff, reviews insurance and managed care requirements, monitors lengths of stay, and conducts quality and medical-necessity reviews. The specialist also supports admissions pre-certifications, appeals, peer reviews, reporting, and staff training on documentation and utilization requirements. Other functions and tasks may be assigned.

Requirements

• High school diploma or equivalent.
• Clinical experience, or two or more years of experience working with the facility's population.
• CPR certification and de-escalation and restraint certification; training is available upon hire and offered by the facility.

Nice To Haves

• Associate's, bachelor's, or master's degree in Social Work, Behavioral or Mental Health, Nursing, or a related health field.
• Previous experience in utilization management.
• LPN, RN, LMSW, LCSW, LPC, or LPC-I licensure in the state where the facility provides services, or a current clinical professional license or certification required in that state.
• First aid, if required based on state or facility requirements.

Responsibilities

• Act as liaison between managed care organizations and facility professional clinical staff.
• Conduct reviews in accordance with certification requirements for insurance plans or other managed care organizations, and coordinate communication about reimbursement requirements.
• Monitor patient lengths of stay and extensions, and inform clinical and medical staff about issues that may affect length of stay.
• Gather and develop statistical and narrative information on utilization, non-certified days and their identified causes, appeal information, discharges, and quality of services, as required by facility leadership or the corporate office.
• Conduct quality reviews for medical necessity and services provided.
• Facilitate peer review calls between the facility and external organizations.
• Initiate and complete the formal appeal process for denied admissions or continued stay.
• Assist the admissions department with pre-certifications of care.
• Provide ongoing support and training for staff on documentation or charting requirements, continued stay criteria, and medical necessity updates.
• Perform other functions and tasks as assigned.

What This Job Offers

• Education Level: High school or GED