Utilization Review Specialist

Acadia • Austin, TX

274d

About The Position

Proactively monitor utilization of services for patients to optimize reimbursement for the facility. 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.

Requirements

• Associate's degree in nursing (LPN or RN) required.
• Bachelor's or Master's degree in social work, behavioral or mental health, nursing or other related health field preferred.
• Two or more years' experience with the population of the facility and previous experience in utilization management preferred.
• Current licensure as an LPN or RN 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.

Nice To Haves

• Experience in utilization management.

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) according to certification requirements.
• Coordinate the flow of communication concerning reimbursement 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.

Benefits

• Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities.

What This Job Offers

• Industry: Furniture, Home Furnishings, Electronics, and Appliance Retailers
• Education Level: Associate degree