Utilization Specialist

Lakeview Behavioral Health • Norcross, GA

1d

About The Position

The Utilization Specialist proactively monitors utilization of services for patients to optimize reimbursement for the facility. This role serves as a liaison between managed care organizations and facility clinical staff, reviews care in accordance with certification requirements, monitors length of stay, and supports appropriate reimbursement and medical necessity documentation. The position also provides staff support and training related to documentation, continued-stay criteria, and medical necessity updates. Management may add or remove duties as circumstances require.

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; or a current clinical professional license or certification required in 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 stays.
• 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.

What This Job Offers

• Job Type: Full-time
• Education Level: High school or GED