Utilization & Reimbursement Specialist

Riverwoods Behavioral Health System; Riverdale (GA); On-site; USD 65,000 - 90,000; Full time

Job summary

Riverwoods Behavioral Health System in Georgia seeks a utilization management liaison to optimize reimbursement and care efficiency. You will collaborate with clinical staff and managed care partners to review plans, monitor length of stay, and report on utilization and outcomes.

The role requires clinical experience and preferred utilization management background, with responsibilities including pre-certifications, appeals, and staff training on documentation and medical necessity updates.

Qualifications

• Clinical experience is required or two+ years working with the facility's population.
• Preferred utilization management experience.
• Experience coordinating with managed care organizations and clinical staff.
• Ability to gather and present utilization data and reporting requirements.

Responsibilities

• Act as liaison between managed care organizations and the facility clinical staff.
• Conduct reviews of insurance plans or MCOs and coordinate communication on reimbursement requirements.
• Monitor patient length of stay and inform staff on related issues.
• Gather data to report utilization, non-certified days, discharges and quality of services.
• Conduct quality reviews for medical necessity and services provided.
• Facilitate peer review calls with external organizations.
• Initiate and complete the appeal process for denied admissions.
• Assist admissions with pre-certifications of care.
• Provide staff training on documentation and medical necessity updates.
• Perform other functions as assigned.

Skills

Clinical experience

Utilization management

Communication with MCOs

Staff training

Education

High school diploma or equivalent

Associate's/Bachelor's/Master’s in Social Work or Behavioral Health

Job description

Riverwoods Behavioral Health System in Georgia seeks a utilization management liaison to optimize reimbursement and care efficiency. You will collaborate with clinical staff and managed care partners to review plans, monitor length of stay, and report on utilization and outcomes.

The role requires clinical experience and preferred utilization management background, with responsibilities including pre-certifications, appeals, and staff training on documentation and medical necessity updates.