Utilization Review Specialist
Utilization Review Specialist
Posted on :
30-04-2025
Employer Active
1 Vacancy
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Job Description
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 noncertified 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 precertifications 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:
- Associates degree in nursing (LPN or RN) required. Bachelors or Masters degree in social work behavioral or mental health nursing or other related health field preferred.
- Two or more years experience with the population of the facility and previous experiencein utilization management preferred.
LICENSES/DESIGNATIONS/CERTIFICATIONS:
- Current licensure as an LPN or RN 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 deescalation and restraint certification required (training available upon hire and offered by facility.
- First aid may be required based on state or facility requirements.
SHIFT:
- Monday Friday from 8 a.m. to 5:00 p.m.
Required Experience:
Unclear Seniority
Employment Type
Full-Time
Key Skills
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