Utilization Specialist

Acadia Healthcare • Norcross, GA

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, reviews insurance plans and managed care organization requirements, monitors length of stay, and supports reimbursement-related communication and processes. The specialist also conducts medical necessity and quality reviews, manages appeals, supports pre-certifications, and provides staff education on documentation and utilization requirements.

The position requires a high school diploma or equivalent. Clinical experience is required, or at least two years of experience working with the facility’s population. An associate’s, bachelor’s, or master’s degree in social work, behavioral or mental health, nursing, or a related health field is preferred. Utilization management experience and relevant state licensure or certification are preferred. CPR and de-escalation and restraint certification are required; training is available upon hire. First aid may be required depending on state or facility requirements.

Requirements

• High school diploma or equivalent.
• Clinical experience, or two or more 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.

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, where required by state or facility requirements.

Responsibilities

• Act as liaison between managed care organizations and facility professional clinical staff.
• Conduct reviews of insurance plans or other managed care organizations in accordance with certification requirements, 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 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