Impactful Utilization & Reimbursement Specialist

Socket.dev; Brooksville (FL); On-site; USD 52,000 - 76,000; Full time

Job summary

Sabal Palms Recovery Center in Brooksville, FL is seeking a Full-Time Utilization Review Specialist to monitor patient service utilization and optimize facility reimbursement. You will liaise with managed care organizations and clinical staff, conduct plan reviews, and support admissions with pre-certifications.

Qualifications include a high school diploma and clinical experience; preferred are degrees in social work, mental health, nursing, or related fields, plus UR or utilization management

Qualifications

• Requires clinical experience or two+ years working with the facility's population.
• Preferred degrees include social work, behavioral/mental health, nursing, or related health field.
• Experience in utilization management preferred.

Responsibilities

• Monitor utilization of services to optimize reimbursement for the facility.
• Act as liaison between managed care organizations and clinical staff.
• Conduct reviews of plans or MCO requirements for reimbursement.
• Monitor length of stay and inform staff of issues impacting stay.
• Gather data and report on utilization, discharges, and quality of services.
• Perform quality reviews for medical necessity and services.
• Facilitate peer review calls with external organizations.
• Initiate and complete appeals for denied admissions or continued stay.
• Assist admissions with pre-certifications of care.
• Provide staff training on documentation, stay criteria, and medical necessity updates.
• Perform other duties as assigned.

Skills

Clinical experience

Utilization review knowledge

Documentation accuracy

Education

High school diploma or equivalent

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

CPR certification

De-escalation training

Restraint certification

First aid certification

Job description

Sabal Palms Recovery Center in Brooksville, FL is seeking a Full-Time Utilization Review Specialist to monitor patient service utilization and optimize facility reimbursement. You will liaise with managed care organizations and clinical staff, conduct plan reviews, and support admissions with pre-certifications.

Qualifications include a high school diploma and clinical experience; preferred are degrees in social work, mental health, nursing, or related fields, plus UR or utilization management