Utilization Coordinator

Acadia Healthcare; San Juan (PR); On-site; USD 52,000 - 70,000; Full time

Job summary

Acadia Healthcare is looking for a healthcare professional to proactively monitor utilization of services and optimize reimbursement for our facility in San Juan, Puerto Rico. You will act as a liaison between managed care organizations and clinical staff, conduct reviews for reimbursement, and help ensure medical necessity is met.

The role requires clinical experience (2+ years preferred) and certifications such as CPR/de-escalation.

Qualifications

• Clinical experience or 2+ years working with the facility's population.
• Preferred: utilization management experience.
• CPR and de-escalation/restraint certification required.
• First aid may be required depending on state or facility requirements.

Responsibilities

• Act as liaison between managed care organizations and the facility professional clinical staff.
• Conduct reviews, per certification requirements, of insurance plans or other MCOs and coordinate the flow of communication on reimbursement.
• Monitor patient length of stay and extensions and inform clinical staff of issues affecting stay.
• Gather and develop data to report on utilization, non-certified days, 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 the admissions department with pre-certifications of care.
• Provide ongoing staff training on documentation/ charting requirements and continued stay criteria.

Skills

Clinical experience

Utilization management

MCO liaison

Staff training

Education

High school diploma

Related health degree

Job description

Proactively monitor utilization of services for patients to optimize reimbursement for the facility.

Purpose Statement

Proactively monitor utilization of services for patients to optimize reimbursement for the facility.

Essential Functions

• 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 (including identified causes and appeal information), discharges and quality of services, as required by the facility 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.

Other Functions

• Perform other functions and tasks as assigned.

Education/Experience/Skill Requirements

• 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

Licenses/Designations/Certifications

• Preferred Licensure: LPN, RN, LMSW, LCSW, LPC, LPC-I within the state where the facility provides services; or current clinical professional license or certification, as required, within the state where the facility provides services.
• CPR and de-escalation and restraint certification required (training available upon hire and offered by facility.
• First aid may be required based on state or facility requirements.

Additional Regulatory Requirements

While this job description is intended to be an accurate reflection of the requirements of the job, management reserves the right to add or remove duties from particular jobs when circumstances (e.g. emergencies, changes in workload, rush jobs or technological developments) dictate.

We are committed to providing equal employment opportunities to all applicants for employment regardless of an individual’s characteristics protected by applicable state, federal and local laws.