Utilization & Reimbursement Specialist

Acadia Healthcare; Moosic (Lackawanna County); On-site; USD 65,000 - 90,000; Full time

Job summary

Acadia Healthcare seeks a qualified professional to monitor service utilization and support reimbursement efforts across the facility. The role liaises with managed care organizations and clinical staff to ensure accurate pre-certifications and compliance with medical necessity criteria.

You will review plans, track length of stay, and compile data for reporting on utilization and quality of care, while supporting staff through documentation updates and appeals processes.

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 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

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 extensions 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 (including identified causes and appeal information), discharges and quality of services, as required by the facility leadership or corporate office.
• 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.

Skills

Clinical experience

Utilization management

Communication skills

Documentation

Education

High school diploma or equivalent

Associate's, Bachelor's, or Master’s in Social Work, Behavioral/Mental Health, Nursing, or related health field

Job description

Acadia Healthcare seeks a qualified professional to monitor service utilization and support reimbursement efforts across the facility. The role liaises with managed care organizations and clinical staff to ensure accurate pre-certifications and compliance with medical necessity criteria.

You will review plans, track length of stay, and compile data for reporting on utilization and quality of care, while supporting staff through documentation updates and appeals processes.