Utilization & Reimbursement Specialist

Acadia Healthcare; Wesley Chapel (FL); On-site; USD 55,000 - 75,000; Full time

Job summary

Acadia Healthcare in Florida is seeking a Utilization Management Specialist to monitor medical necessity and optimize reimbursement for our facility. The role collaborates with clinical staff and managed care organizations to ensure compliant review and reporting.

You will conduct pre-certifications, support staff with documentation, and coordinate appeals for denied admissions, while upholding regulatory requirements and patient-centered care.

Qualifications

• Clinical experience is required, or two or more years working with the facility's population (utilization context).
• Preferred licensure includes LPN, RN, LMSW, LCSW, LPC, or LPC-I as applicable in the state.
• CPR and de-escalation and restraint certification required.
• High school diploma or equivalent; higher degrees in Social Work, Behavioral/Mental Health, Nursing, or related health field preferred.

Responsibilities

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

Skills

Clinical experience

Utilization management

Communication

Education

High school diploma or equivalent

Advanced health-related degree

Job description

Acadia Healthcare in Florida is seeking a Utilization Management Specialist to monitor medical necessity and optimize reimbursement for our facility. The role collaborates with clinical staff and managed care organizations to ensure compliant review and reporting.

You will conduct pre-certifications, support staff with documentation, and coordinate appeals for denied admissions, while upholding regulatory requirements and patient-centered care.