Utilization Specialist

Lakeland Behavioral Health System • Springfield, MO

3d

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 clinical staff, reviews insurance and managed care requirements, monitors patient length of stay, and supports medical necessity reviews and reimbursement processes.

The specialist gathers utilization and quality information, facilitates peer review calls, manages formal appeals for denied admissions or continued stays, assists with pre-certifications, and provides staff support and training on documentation, 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 and de-escalation and restraint certification are required; 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, if required by state or facility requirements.

Responsibilities

• Act as liaison between managed care organizations and the facility's professional clinical staff.
• Conduct reviews in accordance with certification requirements for insurance plans or other managed care organizations, and coordinate communication concerning 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 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 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
• Education Level: High school or GED