Utilization & Reimbursement Navigator

Harboroaks; Glenmaura (PA); On-site; USD 52,000 - 86,000; Full time

Job summary

Harboroaks is seeking a Healthcare Utilization Management professional to proactively monitor service utilization and optimize reimbursement for the facility. The role involves reviewing plans with MCOs, coordinating communications on requirements, and supporting clinical staff across documentation and stay criteria.

The ideal candidate has clinical experience and familiarity with utilization management, with responsibilities spanning quality reviews, pre-certifications, and facilitating

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 related health field.
• Experience: Clinical experience is required, or two or more years' experience with the facility's population.

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 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, and dispositions as required.
• 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

Communication skills

Staff training

Education

High school diploma

Associate's/Bachelor's/Master's in Social Work or related health field

Job description

Harboroaks is seeking a Healthcare Utilization Management professional to proactively monitor service utilization and optimize reimbursement for the facility. The role involves reviewing plans with MCOs, coordinating communications on requirements, and supporting clinical staff across documentation and stay criteria.

The ideal candidate has clinical experience and familiarity with utilization management, with responsibilities spanning quality reviews, pre-certifications, and facilitating