Utilization Specialist - PART TIME WEEKENDS (on-site)

Cross Creek Hospital Together with Ascension Seton; Austin (TX); On-site; USD 65,000 - 90,000; Full time

Job summary

Cross Creek Hospital Together with Ascension Seton seeks a qualified professional to monitor service utilization, coordinate with managed care plans, and ensure compliance with certification requirements.

The role involves reviewing plans, tracking length of stay, collecting data, and supporting staff with documentation and medical necessity updates; strong collaboration with clinical teams is required.

Qualifications

• Education: High school diploma or equivalent.
• Preferred: Associate's, Bachelor's, or Master's in Social Work, Behavioral/Mental Health, Nursing, or related health field.
• Experience: Clinical experience or 2+ years working with facility population; utilization management preferred.

Responsibilities

• Act as liaison between managed care organizations and clinical staff.
• Conduct reviews of insurance plans or MCOs and coordinate reimbursement communication.
• Monitor patient length of stay and inform staff on issues affecting stay.
• Gather and develop data reporting on utilization, non-certified days, discharges, and service quality.
• Conduct quality reviews for medical necessity and services.
• 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 training for staff on documentation, stay criteria, and medical necessity updates.
• Perform other functions as assigned.

Skills

Communication

Analytical

Documentation

Regulatory

Education

Degree in health field

Job description

PURPOSE STATEMENT

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

Overview

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 extension s and i nform 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 M aster’s degree in S ocial W ork , B ehavioral or M ental H ealth, N ursing, 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 : LVN/LPN, RN, LMSW, LCSW, LPC, LPC-A 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.

CRSCK