Utilization Specialist
About The Position
The Utilization Specialist proactively monitors patient service utilization to optimize facility reimbursement. The role serves as a liaison between managed care organizations and facility clinical staff, conducts reviews in accordance with certification requirements, and coordinates communication about reimbursement requirements. It monitors length of stay and extensions, conducts medical-necessity and service-quality reviews, supports pre-certifications, and manages appeals for denied admissions or continued stays. The specialist also prepares utilization-related information and provides ongoing staff support and training on documentation, continued-stay criteria, and medical-necessity updates.
Requirements
- High school diploma or equivalent.
- Clinical experience, or two or more years of experience working with the facility's population.
- CPR certification and de-escalation and restraint certification are required; training is available upon hire and offered by the facility.
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, or a current clinical professional license or certification required within that state.
- First aid may be required based on state or facility requirements.
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 impact length of stay.
- Gather and develop statistical and narrative information about utilization, non-certified days and their identified 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 stays.
- 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.
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Education Level
High school or GED
