Utilization & Reimbursement Specialist

Haverhill Pavilion Behavioral Health; Haverhill (MA); On-site; USD 60,000 - 90,000; Full time

Job summary

Haverhill Pavilion Behavioral Health is seeking a qualified professional to monitor service utilization and support reimbursement processes. The role acts as liaison between managed care organizations and the facility staff, conducts plan reviews, and coordinates communications about reimbursement requirements.

Responsibilities include monitoring patient length of stay, gathering data, performing medical-necessity quality reviews, and initiating appeal processes for denied admissions.

Qualifications

• High school diploma or equivalent required.
• Preferred degrees in Social Work, Behavioral or Mental Health, Nursing, or related health field.
• Clinical experience required, or two or more years working with the facility's population; utilization management experience preferred.

Responsibilities

• Act as liaison between managed care organizations and facility staff.
• Conduct reviews of insurance plans for certification and coordinate reimbursement communications.
• Monitor patient length of stay and inform staff of issues that may impact stay.
• Gather and report utilization data, non-certified days, discharges and quality of services.
• Conduct quality reviews for medical necessity and services provided.
• 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 ongoing staff training on documentation, stay criteria, and medical necessity updates.
• Perform other functions and tasks as assigned.

Skills

Clinical experience

Utilization management

Communication

Data gathering

Education

High school diploma or equivalent

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

Job description

Haverhill Pavilion Behavioral Health is seeking a qualified professional to monitor service utilization and support reimbursement processes. The role acts as liaison between managed care organizations and the facility staff, conducts plan reviews, and coordinates communications about reimbursement requirements.

Responsibilities include monitoring patient length of stay, gathering data, performing medical-necessity quality reviews, and initiating appeal processes for denied admissions.