Utilization Specialist: Reimbursement & Care Optimization

Harboroaks; Wilmington (NC); On-site; USD 60,000 - 80,000; Full time

Job summary

Harboroaks seeks a dedicated professional to proactively monitor service utilization and optimize reimbursement for the facility.

You will liaise between managed care organizations and clinical staff, conduct reviews to ensure compliance, and assist with pre-certifications and appeals. The role requires clinical experience and relevant certifications, with emphasis on medical necessity reviews and staff training.

Qualifications

• Clinical experience required, or 2+ years working with the facility's population.
• Preferred licensure: LPN, RN, LMSW, LCSW, LPC, or equivalent.
• CPR and de-escalation and restraint certification required.

Responsibilities

• Act as liaison between MCOs and facility clinical staff.
• Conduct reviews of insurance plans or MCOs and coordinate communication on reimbursement requirements.
• Monitor patient length of stay and inform staff of issues impacting stay.
• Gather and develop data on utilization, non-certified days, discharges, and quality of services.
• 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 admissions with pre-certifications of care.
• Provide training for staff on documentation or charting and continued stay criteria.

Skills

Clinical experience

Utilization management

Communication

Liaison duties

Education

High school diploma

Associate/Bachelor/Master in health field

Tools

MS Office

EMR systems

Job description

Harboroaks seeks a dedicated professional to proactively monitor service utilization and optimize reimbursement for the facility.

You will liaise between managed care organizations and clinical staff, conduct reviews to ensure compliance, and assist with pre-certifications and appeals. The role requires clinical experience and relevant certifications, with emphasis on medical necessity reviews and staff training.