Utilization Specialist

Harboroaks; Madison (WI); On-site; USD 55,000 - 75,000; Full time

Benefits offered by this job

Annual bonus

Medical/dental/vision insurance

401(k) with match

Paid time off

Professional development

Job summary

Harboroaks in Madison, WI is seeking a proactive Utilization Specialist to monitor service utilization and optimize reimbursement for the facility. This on-site role involves coordinating with managed care organizations, staff, and admissions to ensure timely pre-certifications and appeal processes when needed.

The position emphasizes clinical experience or 2+ years in utilization management, with a focus on accuracy in documentation and staying informed on medical necessity updates.

Qualifications

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

Responsibilities

• Act as liaison between managed care organizations and the facility professional clinical staff.
• Conduct reviews of insurance plans or other managed care organizations and coordinate reimbursement communications.
• Monitor patient length of stay and inform staff on issues impacting stay.
• Gather and develop data to report on utilization, non-certified days, discharges and service quality.
• Perform 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 admissions with pre-certifications of care.
• Provide ongoing staff training on documentation, stay criteria, and medical necessity updates.

Job description

Overview

Utilization Specialist

On-site Madison, WI

Full time

Why Join

• Competitive compensation with industry leading annual performance-based bonus opportunity
• Comprehensive benefits including medical, dental, and vision insurance
• 401(k) with company match to support your financial future
• Generous paid time off for vacation, sick days, and holidays
• Professional development & leadership training to sharpen your skills

Purpose Statement

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

Responsibilities

• 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

• 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 equalemployment opportunities to all applicants for employment regardless of an individual’s characteristics protected by applicable state, federal and local laws.

SHOR01

#LI-SWBH