Utilization Specialist

Southwood Children's Behavioral Healthcare • Pittsburgh, PA

2d

About The Position

Southwood Psychiatric Hospital offers comprehensive mental health treatment programs for children and adolescents ages 3-21 whose lives have been disrupted by mental illness. Our facility near Pittsburgh, Pennsylvania, provides many levels of care. Currectly we are lookingto fill an opening for an experienced Utilization Review Specialist to join the UR Team. ​
PURPOSE STATEMENT:
​Proactively monitor utilization of services for patients to optimize reimbursement for the facility.

Requirements

• High school diploma or equivalent.
• Clinical experience is required, or two or more years' experience working with the facility's population.
• CPR and de-escalation and restraint certification required (training available upon hire and offered by 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 is preferred
• LPN, RN, LMSW, LCSW, LPC, LPC-I within the state where the facility provides services; or current clinical professional license or certification, as required, within the state where the facility provides services.

Responsibilities

• Act as liaison between managed care organizations and the facility professional clinical staff.
• Conduct reviews, in accordance with certification requirements, of insurance plans or other managed care organizations (MCOs) and coordinate the flow of communication concerning reimbursement requirements.
• Monitor patient length of stay and extensions and inform clinical and medical staff on issues that may impact length of stay.
• Gather and develop statistical and narrative information to report on utilization, non-certified days (including identified causes and appeal information), discharges and quality of services, as required by the facility leadership or corporate office.
• Conduct quality reviews for medical necessity and services provided.
• Facilitate peer review calls between facility and external organizations.
• Initiate and complete the formal appeal process for denied admissions or continued stay.
• 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
• Career Level: Entry Level
• Education Level: High school or GED
• Number of Employees: 11-50 employees