Utilization Specialist (100% onsite)
About The Position
The Utilization Specialist proactively monitors utilization of services for patients to optimize reimbursement for the facility. This role acts as a liaison between managed care organizations and the facility's professional clinical staff, conducting reviews in accordance with certification requirements of insurance plans or other managed care organizations (MCOs). The specialist coordinates communication regarding reimbursement requirements, monitors patient length of stay and extensions, and informs clinical and medical staff on issues that may impact length of stay. They are responsible for gathering and developing statistical and narrative information to report on utilization, non-certified days, discharges, and quality of services. Additionally, the Utilization Specialist conducts quality reviews for medical necessity and services provided, facilitates peer review calls, initiates and completes the formal appeal process for denied admissions or continued stays, and assists the admissions department with pre-certifications of care. They also provide ongoing support and training for staff on documentation, charting requirements, continued stay criteria, and medical necessity updates.
Requirements
- High school diploma or equivalent.
- Clinical experience is required, or two or more years' experience working with the facility's population.
- 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.
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 is preferred.
- 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.
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.
- Perform other functions and tasks as assigned.
Benefits
- Training available upon hire for CPR and de-escalation and restraint certification.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
High school or GED
