Utilization & Reimbursement Specialist (As Needed)

East Tennessee Behavioral Health; Knoxville (TN); On-site; USD 52,000 - 75,000; Full time

Job summary

East Tennessee Behavioral Health seeks a qualified professional to monitor service utilization and coordinate reimbursement requirements with managed care organizations. The role includes reviews for medical necessity, admissions appeal processing, and staff training on documentation and stay criteria.

The position requires clinical experience and a high school diploma, with preferred advanced degrees in health-related fields.

Qualifications

• High school diploma or equivalent required.
• Advanced degrees in Social Work, Behavioral or Mental Health, Nursing, or related health field preferred.
• Clinical experience is required, or two or more years' experience working with the facility's population; utilization management experience preferred.

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 (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.

Skills

Clinical experience

Education

High school diploma or equivalent

Associate/Bachelor/Master in Social Work Behavioral or Mental Health Nursing or related health field

Job description

East Tennessee Behavioral Health seeks a qualified professional to monitor service utilization and coordinate reimbursement requirements with managed care organizations. The role includes reviews for medical necessity, admissions appeal processing, and staff training on documentation and stay criteria.

The position requires clinical experience and a high school diploma, with preferred advanced degrees in health-related fields.