Utilization Specialist
About The Position
The Utilization Specialist proactively monitors utilization of services for patients to optimize facility reimbursement. The role serves as a liaison between managed care organizations and facility clinical staff, reviews insurance plans and managed care requirements, monitors patient length of stay, and supports the facility's utilization, medical necessity, and reimbursement processes. The specialist gathers utilization and quality information for facility leadership or the corporate office, conducts medical necessity and service reviews, facilitates peer review calls, and manages appeals for denied admissions or continued stays. The role also assists with admission pre-certifications and provides staff support and training on documentation, charting, continued-stay criteria, and medical necessity updates. Other functions and tasks may be assigned.
Requirements
- High school diploma or equivalent.
- Clinical experience, or two or more years of experience working with the facility's population.
- CPR and de-escalation and restraint certification; training is available upon hire and offered by the 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.
- LPN, RN, LMSW, LCSW, LPC, or LPC-I licensure within the state where the facility provides services; alternatively, a current clinical professional license or certification as required within that state.
Responsibilities
- Act as liaison between managed care organizations and facility professional clinical staff.
- Conduct reviews in accordance with certification requirements for insurance plans or other managed care organizations and coordinate communication concerning reimbursement requirements.
- Monitor patient length of stay and extensions, and inform clinical and medical staff about issues that may affect length of stay.
- Gather and develop statistical and narrative information on utilization, non-certified days and their causes, appeal information, discharges, and quality of services, as required by facility leadership or the corporate office.
- Conduct quality reviews for medical necessity and services provided.
- Facilitate peer review calls between the 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 staff support and training on documentation or charting requirements, continued-stay criteria, and medical necessity updates.
- Perform other functions and tasks as assigned.
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What This Job Offers
Job Type
Full-time
Education Level
High school or GED
