Utilization Specialist (100% onsite)
About The Position
We are seeking a full-time Utilization Specialist responsible for proactively monitoring utilization of services for patients to optimize reimbursement for the facility. Coastal Pines will be a modern, purpose-built facility and a cornerstone of behavioral health care in Northeast Florida, designed to meet the growing demand for high-quality psychiatric services in the region. The 144-bed behavioral health hospital, located in St. Johns, will offer a full continuum of services including inpatient psychiatric care, Partial Hospitalization Program (PHP), Intensive Outpatient Program (IOP), and Electroconvulsive Therapy (ECT).
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
- Competitive compensation package including performance-based incentives
- Comprehensive medical, dental, and vision insurance
- 401(k) plan with company match through Acadia Healthcare
- Equity/stock-based incentive awards for long-term financial growth
- Generous paid time off including vacation, holidays, and sick days
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
High school or GED
