Behavioral Health Utilization Specialist — Reimbursement

Coastal Pines Behavioral Health; Saint Augustine (FL); On-site; USD 52,000 - 72,000; Full time

Benefits offered by this job

Competitive compensation

Medical insurance

401(k) plan with company match

Equity/stock-based incentives

Paid time off

Job summary

Coastal Pines Behavioral Health seeks a full-time Utilization Specialist to proactively monitor service utilization and optimize reimbursement for a 144-bed behavioral health hospital near Jacksonville, FL. The role involves liasing with managed care organizations, reviewing plans, and guiding clinical staff on reimbursement requirements.

The candidate will analyze length of stay, gather data for reports, and conduct medical necessity reviews.

Qualifications

• Clinical experience is required or two years' experience working with the facility's population
• Experience in utilization management is preferred
• Preferred education in Social Work / Behavioral or Mental Health / Nursing or related health field

Responsibilities

• Act as liaison between managed care organizations and the facility professional clinical staff
• Conduct reviews of insurance plans or other managed care organizations and coordinate the flow of communication concerning reimbursement requirements
• Monitor patient length of stay and extensions and inform clinical staff on issues that may impact length of stay
• Gather and develop statistical and narrative information to report on utilization, non-certified days, discharges and quality of services
• Conduct quality reviews for medical necessity and services provided
• Facilitate peer review calls between facility and external organizations
• Initiate and complete the formal appeal process for denied admissions or continued stay
• 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

Skills

Utilization management

Education

Associate/Bachelor/Master in Social Work, Behavioral or Mental Health, Nursing or related health field

High school diploma or equivalent

Job description

Coastal Pines Behavioral Health seeks a full-time Utilization Specialist to proactively monitor service utilization and optimize reimbursement for a 144-bed behavioral health hospital near Jacksonville, FL. The role involves liasing with managed care organizations, reviewing plans, and guiding clinical staff on reimbursement requirements.

The candidate will analyze length of stay, gather data for reports, and conduct medical necessity reviews.