Strategic Utilization & Reimbursement Specialist

Harboroaks; Madison (WI); On-site; USD 55,000 - 75,000; Full time

Benefits offered by this job

Annual bonus

Medical/dental/vision insurance

401(k) with match

Paid time off

Professional development

Job summary

Harboroaks in Madison, WI is seeking a proactive Utilization Specialist to monitor service utilization and optimize reimbursement for the facility. This on-site role involves coordinating with managed care organizations, staff, and admissions to ensure timely pre-certifications and appeal processes when needed.

The position emphasizes clinical experience or 2+ years in utilization management, with a focus on accuracy in documentation and staying informed on medical necessity updates.

Qualifications

• High school diploma or equivalent required.
• Preferred: Associate's, Bachelor's, or Master’s degree in Social Work, Behavioral or Mental Health, Nursing, or related health field.
• Experience: Clinical experience required, or two or more years working with the facility's population; utilization management experience preferred.

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 reimbursement communications.
• Monitor patient length of stay and inform staff on issues impacting stay.
• Gather and develop data to report on utilization, non-certified days, discharges and service quality.
• Perform 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, stay criteria, and medical necessity updates.

Job description

Harboroaks in Madison, WI is seeking a proactive Utilization Specialist to monitor service utilization and optimize reimbursement for the facility. This on-site role involves coordinating with managed care organizations, staff, and admissions to ensure timely pre-certifications and appeal processes when needed.

The position emphasizes clinical experience or 2+ years in utilization management, with a focus on accuracy in documentation and staying informed on medical necessity updates.