Clinical Utilization & Reimbursement Specialist

Harboroaks; Greenville (NC); On-site; USD 65,000 - 90,000; Full time

Job summary

Harboroaks is seeking a healthcare utilization management liaison to optimize reimbursement by monitoring service utilization and coordinating with clinical staff. The role requires clinical experience and familiarity with MCO policies to ensure compliance and efficient patient throughput.

Key responsibilities include handling pre-certifications, appeals for denials, and ongoing staff education on documentation and medical necessity updates.

Qualifications

• Clinical experience required, or two or more years' experience working with the facility's population.
• CPR, de-escalation, and restraint certification required.
• First aid may be required based on state or facility requirements.

Responsibilities

• Act as liaison between managed care organizations and facility staff.
• Conduct reviews of insurance plans or MCOs and coordinate reimbursement communication.
• Monitor patient length of stay and inform staff on issues affecting stay.
• Gather and develop data on utilization, 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 admissions with pre-certifications of care.
• Provide ongoing staff training on documentation and criteria.

Skills

Clinical experience

Utilization management

Education

High school diploma or equivalent

Associate's/Bachelor's/Master’s in Health-related field

Job description

Harboroaks is seeking a healthcare utilization management liaison to optimize reimbursement by monitoring service utilization and coordinating with clinical staff. The role requires clinical experience and familiarity with MCO policies to ensure compliance and efficient patient throughput.

Key responsibilities include handling pre-certifications, appeals for denials, and ongoing staff education on documentation and medical necessity updates.