Utilization & Reimbursement Specialist

Acadia Healthcare; Riverdale (GA); Sur place; USD 60 000 - 90 000; Plein temps

Résumé du poste

Harboroaks is seeking a qualified professional to proactively monitor service utilization to optimize reimbursement for the facility. The role requires clinical experience and focus on ensuring medical necessity through reviews and appeals.

Responsibilities include coordinating with managed care organizations, monitoring length of stay, preparing utilization data, and guiding staff on documentation and pre-certifications. Strong knowledge of utilization management is preferred.

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.

Responsabilités

• 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 (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.
• Perform other functions and tasks as assigned.

Connaissances

Clinical experience

Utilization management

Formation

High school diploma or equivalent

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

Description du poste

Harboroaks is seeking a qualified professional to proactively monitor service utilization to optimize reimbursement for the facility. The role requires clinical experience and focus on ensuring medical necessity through reviews and appeals.

Responsibilities include coordinating with managed care organizations, monitoring length of stay, preparing utilization data, and guiding staff on documentation and pre-certifications. Strong knowledge of utilization management is preferred.