PRN Utilization Specialist

Acadia Healthcare • Knoxville, TN

1d

About The Position

The Utilization Specialist proactively monitors utilization of services for patients to optimize facility reimbursement. The role acts as a liaison between managed care organizations and facility clinical staff, conducts reviews according to certification requirements, and coordinates communication about reimbursement requirements. It monitors patient length of stay and extensions, informs clinical and medical staff of issues that may affect length of stay, and gathers utilization, non-certified-day, discharge, and quality-of-services information for facility leadership or the corporate office.

The position conducts medical-necessity and service-quality reviews, facilitates peer review calls, initiates and completes formal appeals for denied admissions or continued stays, and assists admissions with care pre-certifications. It also provides ongoing staff support and training on documentation and charting requirements, continued-stay criteria, and medical-necessity updates. 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.
• De-escalation and restraint certification; 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 another current clinical professional license or certification required in that state.
• First aid, if required by state or facility requirements.

Responsibilities

• Act as liaison between managed care organizations and facility professional clinical staff.
• Conduct reviews in accordance with certification requirements and coordinate communication about reimbursement requirements.
• Monitor patient length of stay and extensions, and inform clinical and medical staff of 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 for 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

• Education Level: High school or GED