Healthcare Utilization & Reimbursement Specialist

Acadia Healthcare; Hudson (WI); On-site; USD 60,000 - 80,000; Full time

Job summary

Acadia Healthcare is seeking a utilization management specialist to monitor service utilization and support reimbursement for our Wisconsin facility. You will liaise with managed care organizations, conduct reviews for medical necessity, and guide clinical staff on documentation and stay criteria.

The role requires clinical experience and preferred degrees in social work or related health fields, with CPR and de-escalation certifications.

Qualifications

• Requires high school diploma or equivalent.
• Preferred degrees: Associate's, Bachelor's, or Master's in Social Work, Behavioral or Mental Health, Nursing, or related health field.
• Clinical experience required, or 2+ years working with the facility's population; utilization management experience preferred.
• CPR and de-escalation certification required; first aid may be required.

Responsibilities

• Act as liaison between managed care organizations and facility clinical staff.
• Conduct reviews, in accordance with certification requirements, of insurance plans or other managed care organizations (MCOs) and coordinate the flow of communication concerning reimbursement requirements.
• Monitor patient length of stay and extensions and inform clinical and medical staff on issues that may impact length of stay.
• Gather and develop statistical and narrative information to report on utilization, non-certified days (including identified causes and appeal information), discharges and quality of services, as required by the facility leadership or corporate office.
• 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

Liaison & communication

Utilization management

Clinical documentation

Quality reviews

Training & staff support

Data reporting

Education

High school diploma or equivalent

Associate's degree in Social Work / related health field

Bachelor's degree in Social Work / related health field

Master’s degree in Social Work / related health field

Tools

CPR certification

De-escalation training

First aid certification

Job description

Acadia Healthcare is seeking a utilization management specialist to monitor service utilization and support reimbursement for our Wisconsin facility. You will liaise with managed care organizations, conduct reviews for medical necessity, and guide clinical staff on documentation and stay criteria.

The role requires clinical experience and preferred degrees in social work or related health fields, with CPR and de-escalation certifications.