Utilization Management Specialist

Harboroaks; Council Bluffs (IA); On-site; USD 55,000 - 75,000; Full time

Job summary

Harboroaks in Council Bluffs, IA seeks a dedicated utilization management professional to monitor service utilization and optimize reimbursement for the facility. The role involves coordinating with clinical staff and managed care organizations and ensuring compliance with certification requirements.

Key tasks include conducting reviews, monitoring length of stay, reporting utilization data, and leading appeals for denied admissions.

Qualifications

• Clinical experience is required, or two+ years in the facility population.
• Experience in utilization management is preferred.
• Licensure in healthcare is advantageous depending on state requirements.

Responsibilities

• Act as liaison between managed care organizations and facility clinical staff.
• Conduct reviews of insurance plans and coordinate reimbursement requirements.
• Monitor patient length of stay and extensions and inform staff on related issues.
• Gather and report utilization, discharges, and quality of services data as required by leadership.
• Conduct quality reviews for medical necessity and services provided.
• Facilitate peer review calls between the 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 medical necessity updates.
• Perform other functions and tasks as assigned.

Skills

Clinical experience

Utilization management

Interdepartmental liaison

Documentation training

Education

High school diploma or equivalent

Social Work/Behavioral Health/Nursing degree

Job description

Harboroaks in Council Bluffs, IA seeks a dedicated utilization management professional to monitor service utilization and optimize reimbursement for the facility. The role involves coordinating with clinical staff and managed care organizations and ensuring compliance with certification requirements.

Key tasks include conducting reviews, monitoring length of stay, reporting utilization data, and leading appeals for denied admissions.