Utilization Specialist

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

Job summary

The Refuge, an Acadia Healthcare facility in Florida, is seeking a Full Time Utilization Review Specialist to monitor utilization and optimize reimbursement. This on-site position works 40 hours per week, Monday through Friday, with pay starting at $20 per hour.

Responsibilities include liaising between managed care organizations and clinical staff, reviewing plans for medical necessity, and supporting admissions with pre-certifications and formal appeals when needed.

Qualifications

• High school diploma or equivalent required.
• Clinical experience in behavioral health required; 2+ years in utilization management preferred.
• CPR and de-escalation training required; first aid may be required by state/facility.
• Strong communication and coordination with managed care organizations and clinical staff.

Responsibilities

• Act as liaison between managed care organizations and facility clinical staff.
• Conduct reviews of insurance plans and coordinate reimbursement communication.
• Monitor length of stay and extensions; inform staff of potential issues.
• Gather statistical and narrative data on utilization, discharges and quality of services.
• Conduct quality reviews for medical necessity and services.
• Facilitate peer review calls with external organizations.
• Initiate and complete the formal appeal process for denied admissions or continued stay.
• Assist admissions with pre-certifications of care.
• Provide training on documentation, Stay criteria and medical necessity updates.

Skills

Clinical experience

Utilization management

Communication with MCOs

Staff training

Education

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

Job description

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.

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 (e.g. emergencies, changes in workload, rush jobs or technological developments) 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