Utilization Specialist - Especialista de Utilización

Harboroaks; Río Piedras (PR); On-site; USD 50,000 - 80,000; Full time

Job summary

Harboroaks is seeking a healthcare professional to proactively monitor service utilization and optimize reimbursement for the facility. The role involves liaison work with managed care organizations and the clinical staff to ensure timely, compliant patient care and case management.

The candidate will conduct plan reviews, monitor length of stay, gather data, and perform medical necessity reviews. Experience in utilization management is preferred, with emphasis on documentation and

Qualifications

• Requires clinical experience or two+ years working with the facility's population.
• Preferred experience in utilization management.

Responsibilities

• Act as liaison between managed care organizations and facility staff.
• Conduct reviews of insurance plans and MCOs to coordinate reimbursement requirements.
• Monitor patient length of stay and inform staff on associated issues.
• Gather data to report utilization, discharges and quality of care metrics.
• Perform 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 admissions with pre-certifications of care.
• Provide ongoing staff training on documentation, stay criteria, and medical necessity updates.
• Perform other duties as assigned.

Skills

Clinical experience

Utilization management

Education

High school diploma or equivalent

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

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.