Utilization Review Coordinator

Acadia • Gilbert, AZ

333d

About The Position

The purpose of this position is to proactively monitor the utilization of services for patients to optimize reimbursement for the facility. The role involves acting as a liaison between managed care organizations and the facility's professional clinical staff, conducting reviews in accordance with certification requirements, and coordinating communication regarding reimbursement requirements. The position also entails monitoring patient length of stay, gathering statistical and narrative information for reporting, conducting quality reviews, facilitating peer review calls, and assisting with the formal appeal process for denied admissions or continued stays.

Requirements

• Bachelor's or Master's degree in Social Work, Behavioral or Mental Health, Nursing, or a related health field.
• Clinical experience is required, or two or more years' experience working with the facility's population.
• Previous experience in utilization management is preferred.

Nice To Haves

• Preferred Licensure: LPN, RN, LMSW, LCSW, LPC, LPC-I within the state where the facility provides services.
• Current clinical professional license or certification, as required, within the state where the facility provides services.
• CPR and de-escalation and restraint certification required (training available upon hire).
• First aid may be required based on state or facility requirements.

Responsibilities

• Act as liaison between managed care organizations and the facility professional clinical staff.
• Conduct reviews of insurance plans or other managed care organizations (MCOs) in accordance with certification requirements.
• Monitor patient length of stay and extensions, informing clinical and medical staff on issues that may impact length of stay.
• Gather and develop statistical and narrative information to report on utilization, non-certified days, discharges, and quality of services.
• Conduct quality reviews for medical necessity and services provided.
• Facilitate peer review calls between 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

• Industry: Furniture, Home Furnishings, Electronics, and Appliance Retailers
• Education Level: Bachelor's degree