Utilization Specialist

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

Job summary

The Refuge in Florida is seeking a Full Time Utilization Review Specialist to monitor utilization of services for patients and optimize reimbursement for the facility. This is a Monday-Friday, on-site position working 40 hours per week.

Preferred education includes degrees in Social Work or Behavioral/Mental Health fields. Applicants should have clinical experience and at least two years in behavioral health, with utilization management background favored.

Qualifications

• Clinical experience in behavioral health is required.
• Two or more years working with the facility's population.
• Previous utilization management experience is preferred.

Responsibilities

• Act as liaison between managed care organizations and facility staff.
• Review insurance plans for medical necessity and reimbursement requirements.
• Monitor length of stay and notify staff of potential issues.
• Collect data to report utilization, discharges, and service quality.
• Facilitate appeals for denied admissions or continued stay.
• Support admissions with pre-certifications of care.

Skills

Clinical experience

Utilization management

Communication

Education

Associate's degree

Bachelor's degree

Master's degree

Tools

CPR certification

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.

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