Strategic Utilization & Reimbursement Specialist

Harboroaks; Magee (MS); On-site; USD 48,000 - 72,000; Full time

Job summary

Harboroaks seeks a dedicated professional to proactively monitor service utilization for patients to optimize reimbursement for the facility.

You will act as the liaison between managed care organizations and the facility staff, conduct reviews for certification requirements, and coordinate communications on reimbursement needs. You will monitor length of stay, gather data for reporting, and support staff with documentation and medical necessity updates.

Qualifications

• Clinical experience is required, or two or more years working with the facility's population.
• Preferred education in social work, behavioral or mental health, nursing, or related health field.
• Experience in utilization management is preferred.

Responsibilities

• Act as liaison between managed care organizations and the facility staff.
• Conduct reviews of insurance plans for certification requirements and coordinate communication on reimbursement.
• Monitor patient length of stay and inform staff on issues impacting stay.
• Gather and develop information to report 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 training for staff on documentation, stay criteria, and medical necessity updates.
• Perform other functions as assigned.

Skills

Clinical experience

Utilization management

Education

High school diploma

Health field degree (Assoc/Bach/Master)

Job description

Harboroaks seeks a dedicated professional to proactively monitor service utilization for patients to optimize reimbursement for the facility.

You will act as the liaison between managed care organizations and the facility staff, conduct reviews for certification requirements, and coordinate communications on reimbursement needs. You will monitor length of stay, gather data for reporting, and support staff with documentation and medical necessity updates.