Utilization Specialist

Acadia Healthcare • Hudson, WI

2d

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 according to certification requirements, and coordinates communication about reimbursement requirements. The specialist monitors length of stay, conducts medical-necessity and service-quality reviews, supports pre-certification and appeals, and provides staff training on documentation and continued-stay criteria. Other functions and tasks may be assigned.

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.

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 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 staff support and training 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