Utilization & Reimbursement Specialist

North Tampa Behavioral Health Hospital; Wesley Chapel (FL); On-site; USD 52,000 - 76,000; Full time

Job summary

North Tampa Behavioral Health Hospital is seeking a utilization management professional to monitor service utilization and optimize reimbursement for the facility. The role involves coordinating with managed care organizations and clinical staff to ensure compliance with certification requirements and admission criteria.

The incumbent will analyze utilization data, support staff with documentation, and lead the appeal process for denied stays.

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.

Responsibilities

• Act as liaison between managed care organizations and the facility professional clinical staff.
• Conduct reviews of insurance plans or other MCOs and coordinate communication concerning reimbursement requirements.
• Monitor patient length of stay and extensions and inform staff on issues affecting length of stay.
• Gather and report statistics on utilization, discharges, and quality of services.
• 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 admissions with pre-certifications of care.
• Provide ongoing staff training on documentation, continued stay criteria, and medical necessity updates.

Skills

Clinical experience

Utilization management

Staff training

Education

High school diploma or equivalent

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

Job description

North Tampa Behavioral Health Hospital is seeking a utilization management professional to monitor service utilization and optimize reimbursement for the facility. The role involves coordinating with managed care organizations and clinical staff to ensure compliance with certification requirements and admission criteria.

The incumbent will analyze utilization data, support staff with documentation, and lead the appeal process for denied stays.