Utilization Specialist

Harboroaks; Magee (MS); On-site; USD 45,000 - 75,000; Full time

Job summary

Harboroaks in Mississippi seeks a dedicated Utilization Review Specialist to monitor patient service utilization and optimize reimbursement for the facility. You will liaise with managed care plans and clinical staff, ensuring compliance with certification requirements and coordinating communication on reimbursement needs.

The role requires on-site work, clinical experience, and proficiency in reviewing medical necessity and authorization processes, with duties extending to staff education on

Qualifications

• Required education: high school diploma or equivalent.
• Preferred degrees in Social Work, Behavioral or Mental Health, Nursing, or related health field.
• Experience: utilization review experience required; clinical experience with the facility's population preferred.
• Must work on site at the facility.

Responsibilities

• Act as liaison between managed care organizations and the facility clinical staff.
• Conduct reviews of insurance plans or MCOs and coordinate communication on reimbursement requirements.
• Monitor patient length of stay and inform staff on issues that may impact length of stay.
• Gather and develop data to report on utilization, discharges and quality of services.
• Conduct quality reviews for medical necessity and services provided.
• Facilitate peer review calls with external organizations.
• Initiate and complete the formal appeal process for denied admissions or continued stay.
• Assist admissions with pre-certifications of care.
• Provide ongoing support and training for staff on documentation and stay criteria updates.

Skills

Utilization review experience

Clinical experience

On-site work

Education

High school diploma or equivalent

Associate's degree

Bachelor's degree

Master’s degree

Job description

Overview

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: Utilization Review Expierence is Required; Clinical experience is required, or two or more years' experience working with the facility's population.
• Must work on site at our facility.

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.