Strategic Utilization & Reimbursement Specialist

Erlanger Health System; Riverdale (GA); On-site; USD 60,000 - 80,000; Full time

Job summary

Erlanger Health System in Georgia is seeking a candidate for a role in utilization management to monitor service utilization and optimize reimbursement for the facility. The position involves coordinating with managed care organizations, reviewing plans for medical necessity, and supporting staff with documentation and criteria for continued stay.

The ideal candidate has clinical experience and, ideally, some exposure to utilization management within a hospital setting.

Qualifications

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

Responsibilities

• Act as liaison between managed care organizations and the facility professional 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, discharges and quality of services, as required by 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

Clinical experience

Utilization management

Education

High school diploma or equivalent

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

Job description

Erlanger Health System in Georgia is seeking a candidate for a role in utilization management to monitor service utilization and optimize reimbursement for the facility. The position involves coordinating with managed care organizations, reviewing plans for medical necessity, and supporting staff with documentation and criteria for continued stay.

The ideal candidate has clinical experience and, ideally, some exposure to utilization management within a hospital setting.