Utilization Management & Reimbursement Specialist

Harboroaks; Peachtree Corners (GA); On-site; USD 55,000 - 75,000; Full time

Job summary

Harboroaks is seeking a Healthcare Utilization Management Specialist to proactively monitor service utilization and optimize reimbursement for the facility. The role involves coordinating with managed care organizations and clinical staff to ensure medical necessity and proper discharge planning.

You will conduct reviews, report on utilization metrics, facilitate peer reviews, assist with pre-certifications, and train staff on documentation and continued stay criteria.

Qualifications

• Required Education: High school diploma or equivalent.
• Preferred degrees: Associate, Bachelor’s, or Master’s in Social Work, Behavioral or Mental Health, Nursing, or related health field.
• 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 (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.

Skills

Clinical experience

Utilization management

Communication with MCOs

Education

High school diploma or equivalent

Advanced degree in Social Work or related health field

Job description

Harboroaks is seeking a Healthcare Utilization Management Specialist to proactively monitor service utilization and optimize reimbursement for the facility. The role involves coordinating with managed care organizations and clinical staff to ensure medical necessity and proper discharge planning.

You will conduct reviews, report on utilization metrics, facilitate peer reviews, assist with pre-certifications, and train staff on documentation and continued stay criteria.