Acute Utilization & Discharge Specialist

The Pavilion at Williamsburg Place; Williamsburg (VA); On-site; USD 65,000 - 85,000; Full time

Job summary

The Pavilion at Williamsburg Place in Williamsburg, VA seeks a diligent Utilization Specialist- Acute to review admissions, stays, and discharge planning according to approved criteria.

The role coordinates with insurance providers, physicians, and the admissions team to obtain authorizations, verify benefits, and ensure accurate documentation. The incumbent supports staff training and contributes to ongoing utilization management.

Qualifications

• Graduation from an approved/accredited school of nursing or a Bachelor's degree in social work, behavioral or mental health, or other related health field required.
• Two or more years of direct clinical experience in a psychiatric or mental health setting required.
• Current licensure as an LPN or RN or current clinical professional license or certification, as required, within the state where the facility provides services.

Responsibilities

• Reviews admissions, concurrent stays, continued stay, and discharge planning using established criteria.
• Communicates with insurance companies, HMOs and similar entities for approval of inpatient days, providing clear clinical information.
• Communicates with physicians and providers regarding utilization issues and trends.
• Appeals denials and coordinates the appeal process, providing information to physicians for appeals.
• Assists admissions with pre-certifications of care and verifies benefits with managed care organizations.
• Maintains accurate documentation related to utilization management.
• Provides ongoing staff training on documentation, criteria, and updates.
• Coordinates with the business office on payment issues and problems.
• Monitors length of stay and informs clinical staff of issues affecting stay length; participates in discharge planning.
• Gathers data for utilization reports and quality reviews; facilitates peer reviews when needed.

Skills

Communication skills

Education

Bachelor’s degree in nursing or related health field; Licensure as LPN/RN

Job description

The Pavilion at Williamsburg Place in Williamsburg, VA seeks a diligent Utilization Specialist- Acute to review admissions, stays, and discharge planning according to approved criteria.

The role coordinates with insurance providers, physicians, and the admissions team to obtain authorizations, verify benefits, and ensure accurate documentation. The incumbent supports staff training and contributes to ongoing utilization management.