Utilization Specialist - RN/LPN Welcome

North Tampa Behavioral Health • Zephyrhills, FL

249d

About The Position

North Tampa Behavioral Health is a private inpatient psychiatric and substance abuse treatment facility located in Wesley Chapel, Florida. The center offers both inpatient and outpatient psychiatric and co-occurring treatment, including a Partial Hospitalization Program and an Intensive Outpatient Program for adults and seniors. They address a broad range of behavioral issues, including depression, substance abuse, anxiety disorders, bipolar disorder, post-traumatic stress disorder, and psychosis. North Tampa Behavioral Health is seeking a dedicated Utilization Specialist to join our team. This role is essential for ensuring the efficient use of healthcare resources and maintaining high standards of patient care. The Utilization Specialist will review patient cases to determine the appropriateness of admissions, continued stays, and discharges, manage authorization procurement, and mitigate concurrent denials.

Requirements

• High school diploma or equivalent.
• 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

• Associate's, Bachelor's, or Master's degree in Social Work, Behavioral or Mental Health, Nursing, or a related health field.
• Preferred Licensure: LPN, RN, LMSW, LCSW, LPC, LPC-I within the state where the facility provides services; or 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 and offered by facility).
• First aid may be required based on state or facility requirements.

Responsibilities

• 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.
• Perform other functions and tasks as assigned.

What This Job Offers

• Industry: Hospitals
• Education Level: High school or GED