Utilization Specialist

Acadia Healthcare; Ocklawaha (FL); On-site; USD 27,552 - 33,062; Full time

Job summary

The Refuge, a Healing Place in Ocklawaha, Florida, part of Acadia Healthcare, is seeking a Full Time Utilization Review Specialist. You will monitor utilization of services to optimize reimbursement and support clinical staff with documentation and pre-certifications.

This 40-hour per week, Monday–Friday day position involves liaising with managed care organizations, reviewing plans for medical necessity, tracking length of stay, and initiating appeal processes for denied admissions.

Qualifications

• Required Education: High school diploma or equivalent.
• Preferred Education: Associate's, Bachelor’s, or Master’s in Social Work or related field.
• Experience: Clinical experience required or 2+ years in the facility's population; utilization mgmt preferred.

Responsibilities

• Act as liaison between managed care organizations and facility staff.
• Conduct reviews of insurance plans and coordinate reimbursement communication.
• Monitor length of stay and inform staff of issues affecting stay.
• Gather data to report utilization, non-certified days, discharges and quality.
• Conduct reviews for medical necessity and services provided.
• Facilitate peer review calls and manage appeal processes for denials.
• Assist admissions with pre-certifications and train staff on documentation.
• Perform other tasks as assigned.

Skills

Clinical experience

Utilization management

Liaison with MCOs

Education

High School Diploma or equivalent

Advanced health degree (preferred)

Job description

Are you prepared for the impact you can make in your UR career at a well-respected treatment center in Ocklawaha, Florida? If so, you may enjoy working at The Refuge, a Healing Place, an trauma treatment facility set on 96-acre campus located in the Ocala National Forest. The Refuge provides premier residential treatment for adults aged 18 and older who are struggling with substance use disorders, behavioral health, trauma, eating disorder and other co-occurring disorders.

We are looking to for a Full Time Utilization Review Specialist to join our team. The UR specialist proactively monitors utilization of services for patients to optimize reimbursement for the facility. This is a Monday-Friday, day position working 40 hours per week.

Purpose Statement

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

Pay for this position ranges from $20 - $24/hr based on relevant work experience.

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

• 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 dictate.

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.

REFHP