Utilization & Reimbursement Specialist

Harboroaks; Highlands (MA); On-site; USD 65,000 - 90,000; Full time

Job summary

Harboroaks seeks a dedicated professional to proactively monitor service utilization and optimize reimbursement for the facility. The role requires coordinating with managed care organizations and clinical staff, conducting reviews, and ensuring medical necessity standards are met.

The candidate should have clinical experience, an appropriate health-field degree, and an active LPN/RN license as required. The position emphasizes collaboration with admissions and staff training on documentation

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 a related health field.
• Experience: Clinical experience is required, or two or more years' experience working with the facility's population.
• Previous experience in utilization management is preferred.
• LPN or RN license or equivalent clinical certification may be required by state.

Responsibilities

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

Skills

Liaison skills

Clinical experience

Documentation

De-escalation

Communication

Education

LPN or RN license

High school diploma or equivalent

Associate/Bachelor/Master in health field

Job description

Harboroaks seeks a dedicated professional to proactively monitor service utilization and optimize reimbursement for the facility. The role requires coordinating with managed care organizations and clinical staff, conducting reviews, and ensuring medical necessity standards are met.

The candidate should have clinical experience, an appropriate health-field degree, and an active LPN/RN license as required. The position emphasizes collaboration with admissions and staff training on documentation