Utilization Review Specialist-PRN

Acadia Healthcare; Columbus (OH); On-site; USD 60,000 - 80,000; Full time

Job summary

An established industry player in healthcare is seeking a dedicated professional to serve as a liaison between managed care organizations and clinical staff. This role involves conducting reviews of insurance plans, monitoring patient length of stay, and gathering vital statistical information to ensure quality services. You will play a crucial role in facilitating communication, conducting quality reviews, and supporting staff with documentation requirements. If you are passionate about improving healthcare services and have a keen eye for detail, this opportunity is perfect for you to make a significant impact in a dynamic environment.

Qualifications

• Strong understanding of managed care organizations and reimbursement processes.
• Experience in conducting quality reviews and statistical reporting.

Responsibilities

• Act as liaison between managed care organizations and clinical staff.
• Monitor patient length of stay and coordinate communication with staff.
• Conduct reviews and facilitate peer review calls for quality assurance.

Skills

Communication Skills

Analytical Skills

Knowledge of Managed Care

Quality Review Skills

Education

Bachelor's Degree in Healthcare Administration or related field

Job description

1. Act as liaison between managed care organizations and the facility professional clinical staff.
2. 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.
3. Monitor patient length of stay and extensions and inform clinical and medical staff on issues that may impact length of stay.
4. 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.
5. Conduct quality reviews for medical necessity and services provided.
6. Facilitate peer review calls between facility and external organizations.
7. Initiate and complete the formal appeal process for denied admissions or continued stay.
8. Assist the admissions department with pre-certifications of care.
9. Provide ongoing support and training for staff on documentation or charting requirements, continued stay criteria and medical necessity updates.