Utilization Specialist

Acadia Healthcare; Wesley Chapel (FL); On-site; USD 55,000 - 75,000; Full time

Job summary

Acadia Healthcare in Florida is seeking a Utilization Management Specialist to monitor medical necessity and optimize reimbursement for our facility. The role collaborates with clinical staff and managed care organizations to ensure compliant review and reporting.

You will conduct pre-certifications, support staff with documentation, and coordinate appeals for denied admissions, while upholding regulatory requirements and patient-centered care.

Qualifications

• Clinical experience is required, or two or more years working with the facility's population (utilization context).
• Preferred licensure includes LPN, RN, LMSW, LCSW, LPC, or LPC-I as applicable in the state.
• CPR and de-escalation and restraint certification required.
• High school diploma or equivalent; higher degrees in Social Work, Behavioral/Mental Health, Nursing, or related health field preferred.

Responsibilities

• Act as liaison between managed care organizations and facility clinical staff.
• Review insurance plans and coordinate communications regarding reimbursement requirements.
• Monitor patient length of stay and inform staff on issues affecting stay.
• Gather and report utilization data, non-certified days, discharges and quality metrics.
• 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 ongoing training for staff on documentation, stay criteria and medical necessity updates.
• Perform other duties as assigned.

Skills

Clinical experience

Utilization management

Communication

Education

High school diploma or equivalent

Advanced health-related degree

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.

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.

AHMKT

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