Utilization Specialist

Socket.dev; Council Bluffs (IA); On-site; USD 45,000 - 65,000; Full time

Job summary

Socket.dev in Council Bluffs, IA seeks a qualified professional to monitor utilization and optimize reimbursement for the facility. You will act as liaison between managed care organizations and the clinical staff, performing reviews and coordinating communications on reimbursement requirements.

Responsibilities include tracking length of stay, gathering reports, ensuring medical necessity, and coordinating pre-certifications and appeals.

Qualifications

• Requires clinical experience, or two+ years in the facility's population.
• Preferred licensure: LPN, RN, LMSW, LCSW, LPC, or similar.
• CPR and de-escalation certification required (training provided).
• First aid may be required.

Responsibilities

• Act as liaison between managed care organizations and facility clinical staff.
• Conduct reviews in accordance with certification requirements and coordinate reimbursement communications.
• Monitor patient length of stay and inform staff on issues affecting length of stay.
• Gather and develop statistical and narrative information to report on utilization, discharges, 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 the admissions department with pre-certifications of care.
• Provide ongoing support and training for staff on documentation or charting requirements.

Skills

Utilization management

Clinical liaison

Data analysis & reporting

Staff training

Education

High school diploma or equivalent

Associate's/Bachelor's/Master’s in Social Work or Nursing or related health field

Job description

PURPOSE STATEMENT:

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

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.

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:

• Preferred Licensure: LPN, RN, LMSW, LCSW, LPC, LPC-I 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.

• 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.

METJEN

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