Strategic Utilization & Reimbursement Specialist

Harboroaks; Burns (TN); On-site; USD 55,000 - 75,000; Full time

Job summary

Harboroaks in Tennessee (Burns) seeks a Utilization Management Specialist to proactively monitor service utilization and optimize reimbursement for the facility, ensuring compliance with certification requirements and patient care standards.

You will act as liaison between managed care organizations and clinical staff, conduct reviews, monitor length of stay, prepare narratives and statistics, facilitate peer reviews, assist with pre-certifications, and provide ongoing education to staff on

Qualifications

• Clinical experience in a healthcare setting is required or two or more years with the facility population.
• Experience in utilization management preferred.

Responsibilities

• Act as liaison between managed care organizations and facility staff.
• Conduct reviews of insurance plans to coordinate reimbursement requirements.
• Monitor patient length of stay and inform staff of issues affecting stay.
• Gather and report statistics on utilization and quality of services.
• Conduct quality reviews for medical necessity and services.
• Facilitate peer review calls with external organizations.
• Initiate and complete formal appeal processes for denials.
• Assist admissions with pre-certifications.
• Provide ongoing staff training on documentation and medical necessity.

Skills

Clinical experience

Utilization management

Communication

Education

High school diploma or equivalent

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

Tools

EMR systems

Job description

Harboroaks in Tennessee (Burns) seeks a Utilization Management Specialist to proactively monitor service utilization and optimize reimbursement for the facility, ensuring compliance with certification requirements and patient care standards.

You will act as liaison between managed care organizations and clinical staff, conduct reviews, monitor length of stay, prepare narratives and statistics, facilitate peer reviews, assist with pre-certifications, and provide ongoing education to staff on