Utilization Specialist

TrustPoint Hospital; Murfreesboro (TN); On-site; USD 55,000 - 75,000; Full time

Benefits offered by this job

Medical Insurance

Dental Insurance

Vision Insurance

HSA/FSA options

Company-paid Life & AD&D

Disability benefits

401(k) with company match

EAP

Paid Holidays

Paid Time Off

Tuition Reimbursement

Job summary

TrustPoint Hospital is seeking a Full Time Utilization Specialist to monitor patient utilization and optimize reimbursement for our behavioral health services. The role involves coordinating with managed care and clinical staff to ensure smooth pre-certifications and appeals processes.

The position requires solid clinical background and utilization management experience, with opportunities for professional growth in a 217-bed facility offering inpatient and outpatient care.

Qualifications

• Required education: high school diploma or equivalent.
• Preferred education: 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+ years' experience with the facility's population.
• Previous experience in utilization management preferred.

Responsibilities

• Act as liaison between managed care organizations and the facility staff.
• Review insurance plans for certification requirements and coordinate reimbursement communication.
• Monitor length of stay and inform staff of issues affecting stay.
• Gather statistics on utilization, non-certified days, discharges and service quality.

Skills

Clinical experience

Utilization management

Communication skills

Education

High school diploma or equivalent

Associate's/Bachelor's/Master’s in Behavioral Health

Job description

Join our team at TrustPoint Hospital as a Full Time Utilization Specialist! We are seeking passionate professionals that are dedicated to behavioral health. If you are looking for unparalleled growth opportunities and are wanting to make a meaningful impact in your community, this is the position for you!

Hours: Mon-Fri 8am-5pm

TrustPoint Hospital is a 217-bed, state-of-the-art treatment center providing comprehensive medical and psychiatric services on both inpatient and outpatient bases. We deliver exceptional care to patients needing acute physical medicine and rehabilitation, adult, adolescent, geriatric psychiatry, and medical psychiatry.

TrustPoint Hospital offers an extensive array of benefits to our valued team members. Current offerings encompass:

• Medical, Dental, and Vision Insurance coverage
• Health Savings Account (HSA) and Flexible Spending Account (FSA) options
• Company-paid Basic Life & AD&D insurance
• Disability benefits
• 401(k) Retirement Plan with a company match
• Employee Assistance Program (EAP) and Employee Discount Program
• Paid Holidays for work-life balance
• Paid Time Off (PTO)
• Tuition Reimbursement opportunities for career advancement

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

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.

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.

AHPILOT