Utilization & Reimbursement Specialist

Harboroaks; El Paso (TX); On-site; USD 52,000 - 76,000; Full time

Job summary

Harboroaks in El Paso, TX is seeking an experienced utilization management professional to proactively monitor service utilization and optimize reimbursement for the facility. You will act as liaison between managed care organizations and clinical staff, conduct reviews for certification requirements, monitor length of stay, and prepare reports on utilization and medical necessity.

This role requires clinical experience, knowledge of payer policies, and the ability to train staff on

Qualifications

• Clinical experience in healthcare settings and utilization management.
• Familiarity with payer policies and medical necessity criteria.
• Ability to coordinate with managed care organizations (MCOs) and clinical staff.

Responsibilities

• Act as liaison between managed care organizations and facility staff.
• Review insurance plans for certification requirements and coordinate reimbursement communications.
• Monitor patient length of stay and inform staff on issues affecting LOS.
• Gather and develop statistical and narrative information on utilization, 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, stay criteria, and medical necessity updates.
• Perform other functions and tasks as assigned.

Skills

Clinical experience

Utilization management

Liaison with MCOs

Quality reviews

Documentation

Education

High school diploma or equivalent

Associate's degree in Social Work or related field

Bachelor's degree in Social Work, Behavioral or Mental Health, Nursing, or related health field

Master’s degree in Social Work or related field

Licensure: LPN, RN, LMSW, LCSW, LPC, or equivalent

Job description

Harboroaks in El Paso, TX is seeking an experienced utilization management professional to proactively monitor service utilization and optimize reimbursement for the facility. You will act as liaison between managed care organizations and clinical staff, conduct reviews for certification requirements, monitor length of stay, and prepare reports on utilization and medical necessity.

This role requires clinical experience, knowledge of payer policies, and the ability to train staff on