Utilization Specialist

Acadia Healthcare; Mount Clemens (MI); On-site; USD 60,000 - 85,000; Full time

Job summary

Acadia Healthcare is expanding with a new facility and seeks a qualified Utilization Management Specialist to support operations in Michigan. You will monitor utilization, coordinate with managed care organizations, and ensure medical necessity reviews meet certification requirements.

The role involves data gathering on length of stay, discharges, and quality of services; facilitating peer reviews and assisting with pre-certifications.

Qualifications

• High school diploma or equivalent required.
• Preferred: Associate's, Bachelor's, or Master's in Social Work, Behavioral or Mental Health, Nursing, or related field.
• Clinical experience required; 2+ years with facility population; utilization management experience preferred.

Responsibilities

• Act as liaison between managed care organizations and facility staff.
• Review insurance plans per certification requirements and coordinate communication on reimbursement.
• Monitor patient length of stay and inform staff of issues affecting stay.
• Gather and report data on utilization, discharges and quality of services.
• Conduct medical necessity reviews.
• Facilitate peer review calls with external organizations.
• Initiate and complete appeals for denied admissions or continued stay.
• Assist admissions with pre-certifications.
• Provide staff training on documentation, stay criteria and medical necessity updates.

Skills

Clinical experience

Utilization management

Education

High school diploma or equivalent

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

Job description

Overview

We are excited to announce the upcoming opening of our new facility, creating additional opportunities for growth, advancement, and career development across our organization.

As we are preparing to expand our services and serve more patients in our community, we are looking for dedicated team members who want to be part of this exciting new chapter.

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

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.