Utilization Specialist

Acadia • Henderson, NV

4d

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, conducts reviews according to certification requirements, and coordinates communications concerning reimbursement requirements. The specialist monitors patient length of stay and extensions, conducts quality and medical-necessity reviews, and supports the admissions department with pre-certifications of care.

The position also gathers and develops statistical and narrative information about utilization, non-certified days and their causes, appeals, discharges, and quality of services as requested by facility leadership or the corporate office. The Utilization Specialist facilitates peer review calls, initiates and completes formal appeals for denied admissions or continued stays, and provides ongoing staff support and training on documentation, charting requirements, continued-stay criteria, and medical-necessity updates. Other functions and tasks may be assigned. Management may add or remove duties as circumstances require.

Requirements

• High school diploma or equivalent.
• Clinical experience, or at least two years of experience working with the facility's population.
• CPR certification 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 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 about 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 support and training to 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