Utilization Specialist

Acadia; Magee (MS); On-site; USD 40,000 - 60,000; Full time

Job summary

Acadia is seeking a dedicated professional to serve as a liaison between managed care organizations and clinical staff in Magee, Mississippi. The ideal candidate will have at least a high school diploma, clinical experience, and knowledge of utilization management. Responsibilities include monitoring patient services, conducting quality reviews, and providing training to staff. This role offers an opportunity to impact patient care and optimize facility reimbursement.

Qualifications

• High school diploma or equivalent is required.
• Preferred education includes a degree in Social Work, Behavioral/Mental Health, or Nursing.
• Clinical experience is required or two years' experience working with the facility's population.

Responsibilities

• Act as liaison between managed care organizations and facility staff.
• Conduct reviews of insurance plans and coordinate communication.
• Monitor patient length of stay and extend stays as needed.
• Gather statistical information for facility leadership.
• Conduct quality reviews for medical necessity.

Skills

Clinical experience

Experience with facility's population

Knowledge of utilization management

Education

High school diploma or equivalent

Associate's degree in Social Work or related field

Bachelor's or Master's degree in related 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.

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.