Utilization Specialist

Rebound Behavioral Health Hospital; Lancaster (SC); On-site; USD 45,000 - 65,000; Full time

Job summary

Rebound Behavioral Health Hospital is seeking a utilization management professional to monitor reimbursement processes and ensure compliant, efficient service delivery. The role focuses on coordinating with managed care organizations and ensuring accurate documentation for approvals.

You will review plans for certification, monitor patient length of stay, and gather metrics to inform leadership. The position includes coordinating appeals for denials and training staff on documentation and

Qualifications

• Required: High school diploma or equivalent.
• Preferred: Associate's, Bachelor's, or Master's in Social Work, Behavioral or Mental Health, Nursing, or related health field.
• Clinical experience is required, or two or more years' experience working with the facility's population.
• Previous experience in utilization management is preferred.

Responsibilities

• Act as liaison between managed care organizations and facility staff.
• Review plans for certification requirements and coordinate communication on reimbursement needs.
• Monitor patient length of stay and inform clinical staff of issues affecting stay.
• Gather and report utilization, non-certified days, discharges, and quality metrics.
• Conduct quality reviews for medical necessity and services provided.
• Facilitate peer review calls between the facility and external organizations.
• Initiate and complete the formal appeal process for denied admissions or continued stay.
• Assist admissions with pre-certifications of care.
• Provide ongoing training for staff on documentation, charting requirements, continued stay criteria, and medical necessity updates.
• Perform other functions as assigned.

Skills

Clinical experience

Utilization management

Staff training

Education

High school diploma or equivalent

Associate's/Bachelor's/Master’s degree in Social Work/Behavioral or Mental Health/Nursing/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 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.

(REBND)