Utilization & Reimbursement Liaison

Acadia Healthcare

San Juan (PR)

On-site

USD 52,000 - 70,000

Full time

14 days+

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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.