Utilization Specialist

Harboroaks; Riverdale (GA); On-site; USD 45,000 - 60,000; Full time

Job summary

Harboroaks in Riverdale, Georgia, is seeking a dedicated professional to monitor patient services and optimize reimbursement for the facility. The role involves acting as a liaison between managed care organizations and clinical staff, reviewing insurance plans, and ensuring quality of services.

A high school diploma is required, with preferred degrees in social work or related health fields. Clinical experience is essential, and relevant licenses within the state are preferred. Join us in maintaining high-quality patient care while contributing to the team's success.

Qualifications

• Required education includes high school diploma or equivalent.
• Preferred education is an associate's, bachelor's, or master's degree in a related health field.
• Clinical experience or two or more years' experience working with the facility's population is needed.

Responsibilities

• Act as a liaison between managed care organizations and clinical staff.
• Conduct reviews of insurance plans and coordinate communication on reimbursement requirements.
• Monitor patient length of stay and inform staff on related issues.

Skills

Clinical experience

Communication skills

Organizational skills

Education

High school diploma or equivalent

Associate's, Bachelor's, or Master’s degree in related field

Job description

Overview

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

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:

• 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.

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.