Utilization Specialist

Geisinger Behavioral Health Center Northeast•Moosic, PA

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 care in accordance with certification requirements, monitors length of stay, and supports medical-necessity and quality reviews. The specialist also gathers utilization and related reporting information, facilitates peer review calls, manages formal appeals, assists with pre-certifications, and provides staff support and training on documentation, continued-stay criteria, and medical-necessity updates. The position requires a high school diploma or equivalent and clinical experience, or at least two years of experience working with the facility's population. An associate, bachelor's, or master's degree in a related health field and utilization-management experience are preferred. Preferred licensure includes relevant clinical credentials valid in the state where the facility provides services. 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. Management may add or remove duties as circumstances dictate. The employer states that it provides equal employment opportunities to applicants regardless of characteristics protected by applicable law.

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.
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 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 about utilization, non-certified days and their causes, appeals, 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 formal appeals 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.