Utilization Review Specialist

Acadia Healthcare; Conway (AR); On-site; USD 60,000 - 80,000; Full time

Job summary

A leading healthcare organization is seeking a professional for a utilization management role to optimize patient care and reimbursement processes. The ideal candidate will have relevant licensure and experience in healthcare settings, ensuring quality service delivery and compliance with managed care requirements.

Qualifications

• 2+ years' experience with the population of the facility.
• Experience in utilization management preferred.
• Current licensure as an LPN or RN required.

Responsibilities

• Monitor utilization of services for patients and optimize reimbursement.
• Act as liaison between managed care organizations and clinical staff.
• Facilitate peer review calls and assist with pre-certifications.

Skills

Utilization Management

Communication

Documentation

Education

Licensed LPN or RN

Bachelor's Degree in Social Work

Master's Degree in Social Work

Job description

PURPOSE STATEMENT:

Proactively monitor utilization of services for patients and optimize reimbursement for the facility. Review for quality of services provided and medical necessity.

ESSENTIAL FUNCTIONS:

Act as liaison between managed care organizations and the facility’s 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.

Inform clinical and medical staff of any specific concerns that would extend or restrict the length of stay of patients.

Keep accurate record of all contact with external organizations and persons who have legitimate interest and legal access to information on the care of patients.

Facilitate peer review calls between facility and external organizations.

Act in coordination with the leadership team of the facility or corporate office to improve the quality of services provided within the organization.

Assist the admissions department with pre-certifications of care.

Initiate and complete the formal appeal process for denied admissions or continued stay.

Provide ongoing support and training for staff on documentation or charting requirements, continued stay criteria and medical necessity updates.

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.

OTHER FUNCTIONS:

Perform other functions and tasks as assigned.

EDUCATION/EXPERIENCE/SKILL REQUIREMENTS:

Licensed LPN or RN, or Associate's Degree, Bachelor's Degree in Social Work, behavioral or mental health, nursing or other related health field; Master's degree in social work, counseling, nursing or related health field preferred. 2+ years' experience with the population of the facility and previous experiencein utilization management preferred

LICENSES/DESIGNATIONS/CERTIFICATIONS:

Current licensure as an LPN or RN within the state where the facility provides services; or current clinical professional license or certification, as required, within the state where the facility provides services

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities
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