Utilization Review Specialist
About The Position
ESSENTIAL FUNCTIONS: Act as liaison between managed care organizations and the facility professional clinical staff. Conduct reviews, in accordance with certification requirements, of insurance plans or other managed care organizations (MCOs) and coordinate the flow of communication concerning reimbursement requirements. Monitor patient length of stay and extensions and inform 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 (including identified causes and appeal information), discharges and quality of services, as required by the facility leadership or corporate office. 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. Hours: Tuesday- Saturday 8:00 am - 5:00 pm
Requirements
- LPN Diploma with a current NC Nursing license OR Associate’s Degree in Nursing (RN) with current NC Nursing license OR Bachelor’s Degree in Social Work, Behavioral Health, Mental Health or other related healthcare field required
- CPR and CPI certification (training offered onsite)
- Teamwork and excellent customer service
Nice To Haves
- Master's Degree in Social work, behavioral Health, Mental Health or other healthcare related field preferred
- Current NC clinical professional licensure/certification preferred
- Two or more years' experience with the population of the facility and previous experience in utilization management preferred.
Responsibilities
- Act as liaison between managed care organizations and the facility professional clinical staff.
- Conduct reviews, in accordance with certification requirements, of insurance plans or other managed care organizations (MCOs) and coordinate the flow of communication concerning reimbursement requirements.
- Monitor patient length of stay and extensions and inform 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 (including identified causes and appeal information), discharges and quality of services, as required by the facility leadership or corporate office.
- 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.
Benefits
- BC/BS Health Insurance (3 plans to choose from, eligible after 30 days of employment)
- Delta Dental (2 plans to choose from)
- NVA Vision Insurance
- Paid life and AD&D insurance
- 401k with a matching contribution
- Vacation/Sick/Extended Sick Personal/Holiday time
- Short term and Long term disability
- Free onsite employee fitness center
- Free meals
- Employee Discount program
- Employee Fun events
- Annual Performance Review and Merit Increase Review
- Salary increases for obtaining education degrees, professional certification and/or licensure (based on program of study/ field of certification and licensure)
- License/Certification renewal and reimbursement
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Number of Employees
5,001-10,000 employees
