Utilization & Reimbursement Specialist

Harboroaks; Río Piedras (PR); On-site; USD 52,000 - 76,000; Full time

Job summary

Harboroaks is seeking a healthcare professional to proactively monitor service utilization to optimize reimbursement for the facility in Puerto Rico. The role involves coordinating with managed care organizations and clinical staff, reviewing plans, and reporting on utilization and quality metrics.

The position requires clinical experience, appropriate certifications, and a high school diploma or higher. You will support staff with documentation, stay criteria, and medical necessity updates

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 in the state where the facility provides services.

Responsibilities

• Act as liaison between managed care organizations and the facility professional 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, 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.
• Perform other functions and tasks as assigned.

Skills

Clinical experience

Communication skills

Attention to detail

Education

High school diploma or equivalent

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

Job description

Harboroaks is seeking a healthcare professional to proactively monitor service utilization to optimize reimbursement for the facility in Puerto Rico. The role involves coordinating with managed care organizations and clinical staff, reviewing plans, and reporting on utilization and quality metrics.

The position requires clinical experience, appropriate certifications, and a high school diploma or higher. You will support staff with documentation, stay criteria, and medical necessity updates