Utilization Management & Care Coordination Specialist

Harboroaks; Austin (TX); On-site; USD 55,000 - 75,000; Full time

Job summary

Harboroaks in Austin, TX is seeking a dedicated professional to monitor utilization of services and optimize reimbursement for the facility. You will liaise with managed care organizations, review plans for medical necessity, and coordinate communications to ensure compliant reimbursement processes.

The role requires clinical experience, certification readiness, and the ability to train staff on documentation and utilization criteria.

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 staff.
• Review insurance plans for medical necessity and coordinate communications on reimbursement requirements.
• Monitor length of stay and inform staff of issues impacting stay.
• Gather data to report utilization, discharges, and quality of services.
• Conduct quality reviews for medical necessity and services.
• Facilitate peer review calls with 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, criteria, and updates.

Skills

Clinical experience

Utilization management

Education

High school diploma or equivalent

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

Job description

Harboroaks in Austin, TX is seeking a dedicated professional to monitor utilization of services and optimize reimbursement for the facility. You will liaise with managed care organizations, review plans for medical necessity, and coordinate communications to ensure compliant reimbursement processes.

The role requires clinical experience, certification readiness, and the ability to train staff on documentation and utilization criteria.