Utilization Management Specialist — Reimbursement

North Tampa Behavioral Health Hospital; Wesley Chapel (FL); On-site; USD 52,000 - 70,000; Full time

Job summary

North Tampa Behavioral Health Hospital in Wesley Chapel, FL is seeking a qualified specialist to monitor utilization of services and support reimbursement workflows, including pre-certifications and communications with managed care organizations.

Candidates should have clinical experience (or 2+ years with the facility population), a High school diploma (or higher), and licensure in related health fields; CPR and de-escalation certifications are preferred.

Qualifications

• Required Education: High school diploma or equivalent.
• Preferred education: Associate's, Bachelor's, or Master’s in Social Work, Behavioral or Mental Health, Nursing, or related 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/Certifications: CPR and de-escalation and restraint certification preferred; current clinical license or certification as required by state.

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 concerning reimbursement requirements.
• Monitor patient length of stay and extensions and inform clinical staff on issues affecting length of stay.
• Gather and develop statistical and narrative information 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 support and training for staff on documentation or charting requirements.

Skills

Clinical experience

Utilization management

Liaison skills

Pre-certification knowledge

Education

High school diploma or equivalent

Associate/Bachelor/Master in Social Work, Behavioral/Mental Health, Nursing or related field

Job description

North Tampa Behavioral Health Hospital in Wesley Chapel, FL is seeking a qualified specialist to monitor utilization of services and support reimbursement workflows, including pre-certifications and communications with managed care organizations.

Candidates should have clinical experience (or 2+ years with the facility population), a High school diploma (or higher), and licensure in related health fields; CPR and de-escalation certifications are preferred.