Utilization & Reimbursement Specialist

Harboroaks; Allenwood (PA); On-site; USD 65,000 - 85,000; Full time

Benefits offered by this job

Restaurant d'entreprise

Indemnités de stage/alternance

Job summary

Harboroaks is seeking a Utilization Management professional to proactively monitor service utilization and optimize reimbursement for the facility. You will act as a liaison between managed care organizations and the facility staff, coordinating communication on reimbursement requirements and denials processes.

Responsibilities include monitoring length of stay, gathering data for reports, conducting reviews for medical necessity, and guiding staff through documentation standards.

Qualifications

• High school diploma or equivalent required.
• Associate’s, Bachelor’s or Master’s degree in Social Work, Behavioral or Mental Health, Nursing, or related health field preferred.
• Clinical experience required, or 2+ years with the facility's population; utilization management experience preferred.

Responsibilities

• Act as liaison between managed care organizations and facility staff.
• Review insurance plans and coordinate reimbursement communication.
• Monitor patient length of stay and inform staff of issues.
• Collect and report utilization data, non-certified days, discharges and quality of services.
• Conduct quality reviews for medical necessity and services.
• Facilitate peer review calls with external organizations.
• Initiate and complete the formal appeal process for denied admissions or continued stay.
• Assist admissions with pre-certifications of care.
• Provide training on documentation and continued stay criteria.

Skills

Clinical experience

Utilization management

Education

High school diploma or equivalent

Associate’s degree

Bachelor’s degree

Master’s degree

Job description

Harboroaks is seeking a Utilization Management professional to proactively monitor service utilization and optimize reimbursement for the facility. You will act as a liaison between managed care organizations and the facility staff, coordinating communication on reimbursement requirements and denials processes.

Responsibilities include monitoring length of stay, gathering data for reports, conducting reviews for medical necessity, and guiding staff through documentation standards.