Utilization & Reimbursement Specialist

Methodist Jennie Edmundson Behavioral Health; Council Bluffs (IA); On-site; USD 60,000 - 90,000; Full time

Job summary

Methodist Jennie Edmundson Behavioral Health seeks a professional to monitor utilization and coordinate reimbursement processes. You will liaise with managed care organizations and internal staff, conduct reviews, and communicate requirements to facilitate appropriate length of stay and patient care.

The ideal candidate has clinical experience and background in utilization management, with strong documentation and training abilities to support staff and ensure medical necessity compliance.

Qualifications

• High school diploma or equivalent required.
• Clinical experience or 2+ years with facility population preferred.
• Experience in utilization management preferred.

Responsibilities

• Act as liaison between managed care organizations and facility staff.
• Conduct reviews of insurance plans or MCOs and coordinate communications on reimbursement requirements.
• Monitor patient length of stay and inform clinical staff on issues affecting stay.
• Gather and develop statistics to report 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 admissions with pre-certifications of care.
• Provide ongoing staff training on documentation, continued stay criteria and medical necessity updates.
• Perform other functions and tasks as assigned.

Skills

Clinical experience

Utilization management

Staff training

Communication

Education

High school diploma or equivalent

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

Job description

Methodist Jennie Edmundson Behavioral Health seeks a professional to monitor utilization and coordinate reimbursement processes. You will liaise with managed care organizations and internal staff, conduct reviews, and communicate requirements to facilitate appropriate length of stay and patient care.

The ideal candidate has clinical experience and background in utilization management, with strong documentation and training abilities to support staff and ensure medical necessity compliance.