Utilization Specialist

Acadia Healthcare; Wilmington (NC); On-site; USD 45,000 - 75,000; Full time

Job summary

Acadia Healthcare in Wilmington, NC seeks a utilization management professional to monitor service utilization and optimize reimbursements for the facility.

You will liaise with managed care organizations, review plans for certification, support admissions, and train staff on documentation and continued stay criteria.

Clinical experience required; state licensure preferred; CPR certification may be required. This role is on-site in Wilmington, NC.

Qualifications

• High school diploma or equivalent required.
• Clinical experience or 2+ years working with the facility's population; utilization management experience preferred.
• State-appropriate licensure (LPN/RN/LMSW/LCSW/LPC or equivalent); CPR certification preferred.

Responsibilities

• Act as liaison between managed care organizations and facility staff for reimbursement.
• Review plans for certification requirements and coordinate related communications.
• Monitor patient length of stay and inform staff of factors impacting stay.
• Gather data on utilization, discharges, and quality of services for leadership review.
• 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 on documentation and continued stay criteria.

Skills

Clinical experience

Utilization management

Documentation & charting

Staff training & support

Education

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

Job description

Purpose Statement

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

Purpose Statement

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

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

• 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 equal employment opportunities to all applicants for employment regardless of an individual’s characteristics protected by applicable state, federal and local laws.