Utilization Specialist

Socket.dev; Brooksville (FL); On-site; USD 52,000 - 76,000; Full time

Job summary

Sabal Palms Recovery Center in Brooksville, FL is seeking a Full-Time Utilization Review Specialist to monitor patient service utilization and optimize facility reimbursement. You will liaise with managed care organizations and clinical staff, conduct plan reviews, and support admissions with pre-certifications.

Qualifications include a high school diploma and clinical experience; preferred are degrees in social work, mental health, nursing, or related fields, plus UR or utilization management

Qualifications

• Requires clinical experience or two+ years working with the facility's population.
• Preferred degrees include social work, behavioral/mental health, nursing, or related health field.
• Experience in utilization management preferred.

Responsibilities

• Monitor utilization of services to optimize reimbursement for the facility.
• Act as liaison between managed care organizations and clinical staff.
• Conduct reviews of plans or MCO requirements for reimbursement.
• Monitor length of stay and inform staff of issues impacting stay.
• Gather data and report on utilization, discharges, and quality of services.
• Perform quality reviews for medical necessity and services.
• Facilitate peer review calls with external organizations.
• Initiate and complete appeals for denied admissions or continued stay.
• Assist admissions with pre-certifications of care.
• Provide staff training on documentation, stay criteria, and medical necessity updates.
• Perform other duties as assigned.

Skills

Clinical experience

Utilization review knowledge

Documentation accuracy

Education

High school diploma or equivalent

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

CPR certification

De-escalation training

Restraint certification

First aid certification

Job description

Overview

Are you prepared for the impact you can make in your UR career at a well-respected treatment center in Brooksville, Florida? If so, you may enjoy working at Sabal Palms Recovery Center, an addiction treatment facility nestled on a 10-acre campus located along Florida's Nature Coast and surrounded by live oak trees. Sabal Palms Recovery Center provides premier residential treatment for adults aged 18 and older who are struggling with addictions.

Our skilled professionals are focused on sharing their knowledge and expertise to help you get acclimated to your new role. Along with detailed training and continual support, our staff will give you the autonomy you need to achieve your career goals. You will love working to make a difference in the lives of our patients as you collaborate with other professionals and a supportive management team.

We are looking to for a Full Time Utilization Review Specialist to join our team. The UR specialist proactively monitors utilization of services for patients to optimize reimbursement for the facility. This is a Monday-Friday, day position working 40 hours per week.

PURPOSE STATEMENT

Proactively monitor utilization of services for patients to optimize reimbursement for the facility.

Responsibilities

ESSENTIAL FUNCTIONS:

• 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.

OTHER FUNCTIONS:

• Perform other functions and tasks as assigned.

Qualifications

EDUCATION/EXPERIENCE/SKILL REQUIREMENTS:

• 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

LICENSES/DESIGNATIONS/CERTIFICATIONS:

• CPR and de-escalation and restraint certification required (training available upon hire and offered by facility.

• First aid may be required based on state or facility requirements.

ADDITIONAL REGULATORY REQUIREMENTS:

While this job description is intended to be an accurate reflection of the requirements of the job, management reserves the right to add or remove duties from particular jobs when circumstances (e.g. emergencies, changes in workload, rush jobs or technological developments) dictate.

We are committed to providing equal employment opportunities to all applicants for employment regardless of an individual’s characteristics protected by applicable state, federal and local laws.

This position requires a Level 2 Background Screening through the Florida Care Provider Background Screening Clearinghouse. In accordance with Florida law, employers must provide applicants with direct access to information about the state’s background screening requirements.

To learn more about disqualifying offenses, exemption procedures, and screening timelines, please visit the Agency for Health Care Administration (AHCA) Background Screening Education & Awareness webpage:

https://info.flclearinghouse.com/education-awareness

Applicants are encouraged to review these requirements before applying.

SABPAL