Utilization Specialist

Acadia Healthcare•Tucson, AZ

About The Position

The Utilization Specialist proactively monitors utilization of services for patients to optimize reimbursement for the facility. The role serves as a liaison between managed care organizations and facility professional clinical staff, reviews insurance and managed-care requirements, and coordinates communications related to reimbursement. The specialist monitors patient length of stay, supports medical-necessity and quality reviews, handles appeals, and helps ensure staff understand documentation and continued-stay requirements. The position requires a high school diploma or equivalent and clinical experience, or at least two years of experience working with the facility’s population. An associate, bachelor’s, or master’s degree in social work, behavioral or mental health, nursing, or a related health field is preferred. Relevant clinical licensure, CPR certification, and de-escalation and restraint certification are preferred or required as specified in the qualifications.

Requirements

High school diploma or equivalent.
Clinical experience, or two or more years of experience working with the facility’s population.
CPR certification required.
De-escalation and restraint certification required; 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, 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.