Utilization Specialist- Acute

The Pavilion at Williamsburg Place; Williamsburg (VA); On-site; USD 65,000 - 85,000; Full time

Job summary

The Pavilion at Williamsburg Place in Williamsburg, VA seeks a diligent Utilization Specialist- Acute to review admissions, stays, and discharge planning according to approved criteria.

The role coordinates with insurance providers, physicians, and the admissions team to obtain authorizations, verify benefits, and ensure accurate documentation. The incumbent supports staff training and contributes to ongoing utilization management.

Qualifications

• Graduation from an approved/accredited school of nursing or a Bachelor's degree in social work, behavioral or mental health, or other related health field required.
• Two or more years of direct clinical experience in a psychiatric or mental health setting required.
• Current licensure as an LPN or RN or current clinical professional license or certification, as required, within the state where the facility provides services.

Responsibilities

• Reviews admissions, concurrent stays, continued stay, and discharge planning using established criteria.
• Communicates with insurance companies, HMOs and similar entities for approval of inpatient days, providing clear clinical information.
• Communicates with physicians and providers regarding utilization issues and trends.
• Appeals denials and coordinates the appeal process, providing information to physicians for appeals.
• Assists admissions with pre-certifications of care and verifies benefits with managed care organizations.
• Maintains accurate documentation related to utilization management.
• Provides ongoing staff training on documentation, criteria, and updates.
• Coordinates with the business office on payment issues and problems.
• Monitors length of stay and informs clinical staff of issues affecting stay length; participates in discharge planning.
• Gathers data for utilization reports and quality reviews; facilitates peer reviews when needed.

Skills

Communication skills

Education

Bachelor’s degree in nursing or related health field; Licensure as LPN/RN

Job description

Utilization Specialist- Acute | The Pavilion at Williamsburg Place | Williamsburg, Virginia

About the Job

The Utilization Specialist is responsible for reviewing of assigned admissions, continued stays, utilization practices and discharge planning according to approved clinically valid criteria which meets the daily deadlines to obtain authorizations and complete other pertinent processes. Coordinates, performs, and monitors all utilization review/management activities of the hospital to continuously improve the collection, reimbursement, coordination, and presentation of utilization review information; Educates hospital staff about requirements and trends.

Roles and Responsibilities

• Performs admission, concurrent, continued stay, and retrospective reviews using the established hospital criteria. Communicates effectively with insurance companies, health maintenance organization (HMOs) and other similar entities for approval of initial or additional inpatient days for treatment. Provides information they need in a logical, concise manner using technical language that accurately describes patient’s condition and need for hospitalization.
• Communicates directly with physicians and other providers with respect to specific inquires and perceived trends of issues as they relate to utilization management.
• Appeals all denials ensuring accuracy of information and effective coordination of correspondence. Initiates, coordinates, and monitors the appeal process. Provides information to physicians to assist them in their role in appeals.
• Assists the admissions department with pre-certifications of care. Performs pre and post admission benefit verification with managed care organizations.
• Maintains accurate documentation and files as it relates to utilization management.
• Provides ongoing support and training for staff on documentation or charting requirements, continued stay criteria and medical necessity updates.
• Communicates effectively with co-workers, program, and nursing staff regarding charting deficiencies and problems/issues identified. Follows up in each instance to determine if corrective action was taken. Notifies supervisor if corrective action is not completed.
• Coordinates information and findings with the business office to help recognize or resolve possible payment problems.
• Monitors patient length of stay and extensions and informs clinical and medical staff on issues that may impact length of stay. Investigates short term length of stays and endeavor to create alternate financial planning which would offer the patient extended days of treatment. Participates in discharge planning as required.
• Gathers and develops 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.
• Conducts quality reviews for medical necessity and services provided. Facilitates peer review calls between facility and external organizations. Identifies potential review problems and discuss them with multi-disciplinary team and/or administration.
• Acts as liaison between managed care organizations and the facility professional clinical staff.
• Assists with any problems encountered during on-site or telephone reviews by the third-party payers or review organization, when necessary.

Education/Requirements

• Graduation from an approved/accredited school of nursing or a Bachelor's degree in social work, behavioral or mental health, or other related health field required.
• Two or more years of direct clinical experience in a psychiatric or mental health setting required.
• Current licensure as an LPN or RN or current clinical professional license or certification, as required, within the state where the facility provides services.

Why The Pavilion at Williamsburg Place?

The Pavilion at Williamsburg Place offers a comprehensive benefit plan and a competitive salary commensurate with experience and qualifications. The Pavilion at Williamsburg Place is an EOE.

Veterans and military spouses are highly encouraged to apply. Summit BHC is dedicated to serving Veterans with specialized programming at our treatment centers across the country. We recognize and value the unique strengths of the military community in supporting our mission to serve those who have served.