Utilization & Reimbursement Specialist

Harboroaks; Highlands (MA); On-site; USD 55,000 - 85,000; Full time

Job summary

Harboroaks is seeking a healthcare utilization management professional to proactively monitor service utilization and optimize reimbursement for the facility. You will serve as the liaison between managed care organizations and the facility's clinical staff, conduct reviews for certification requirements, and report on utilization and quality of services to leadership.

The role requires knowledge of medical necessity policies, the ability to coordinate pre-certifications, and ongoing staff

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.
• Licenses/Certifications: CPR and de-escalation and restraint certification required; licensure preferred as listed.

Responsibilities

• Act as liaison between managed care organizations and facility clinical staff.
• Conduct reviews, in accordance with certification requirements, of insurance plans or other managed care organizations (MCOs) and coordinate the flow of communication concerning reimbursement requirements.
• Monitor patient length of stay and inform clinical and medical staff on issues that may impact length of stay.
• Gather and develop statistical and narrative information to report on 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 the admissions department with pre-certifications of care.
• Provide ongoing support and training for staff on documentation or charting requirements, continued stay criteria and medical necessity updates.

Job description

Harboroaks is seeking a healthcare utilization management professional to proactively monitor service utilization and optimize reimbursement for the facility. You will serve as the liaison between managed care organizations and the facility's clinical staff, conduct reviews for certification requirements, and report on utilization and quality of services to leadership.

The role requires knowledge of medical necessity policies, the ability to coordinate pre-certifications, and ongoing staff