Utilization Specialist

Harboroaks; Ocklawaha (FL); On-site; USD 23,000 - 32,000; Full time

Job summary

Harboroaks seeks a full-time Utilization Review Specialist to monitor service utilization and help optimize reimbursement for the facility. This on-site role supports clinical staff and partners with managed care organizations.

Qualifications include at least a high school diploma; preferred degrees in social work or health fields; two+ years in behavioral health; CPR and related certifications are required. Pay starts at $20/hr, with higher starts for relevant education or experience.

Qualifications

• High school diploma or equivalent required.
• Preferred degrees: Associate's, Bachelor's, or Master's in Social Work, Behavioral/Mental Health, Nursing or related field.
• Clinical experience is required; two+ years in behavioral health; utilization management experience preferred.

Responsibilities

• Act as liaison between managed care organizations and clinical staff.
• Review insurance plans and coordinate reimbursement requirements.
• Monitor length of stay and extensions; alert staff to issues.
• Gather data to report utilization, discharges and quality.
• Conduct medical-necessity reviews of services.
• Facilitate peer review calls with external partners.
• Initiate appeals for denied admissions or stays.
• Assist admissions with pre-certifications.
• Train staff on documentation and stay criteria.
• Perform other duties as assigned.

Education

High school diploma or equivalent

Associate's degree, Bachelor's or Master's in Social Work, Behavioral or Mental Health, Nursing, or related health field

Job description

Overview

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, on-site 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 starts at $20/hr and based on relevant work experience. Higher starting wages for candidates that meet the preferred education criteria will be discussed.

Preferred education: Associate's, Bachelor's or Master's Degree in Social Work, Behavioral or Mental Health, Nursing, or a related health field.

Required experience: Clinical experience is required, 2 or more years experience working in the behavioral health field. Previous experience in utilization management is strongly preferred.

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:

• 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.

REFHP