Utilization Specialist

Acadia Healthcare•Moosic, PA

About The Position

The Utilization Specialist proactively monitors utilization of services for patients to optimize reimbursement for the facility. The role acts as a liaison between managed care organizations and facility professional clinical staff, reviews insurance plans and managed care organization requirements, and coordinates communication concerning reimbursement. It monitors patient length of stay and extensions, conducts medical necessity and quality reviews, supports pre-certifications, and handles appeals for denied admissions or continued stays. The specialist also provides utilization information and supports staff 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.
De-escalation and restraint certification; 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 in that state.
First aid may be required based on state or facility requirements.

Responsibilities

Act as a 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 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.