Utilization Review Specialist Full-time

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 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.

EDUCATION/EXPERIENCE/SKILL REQUIREMENTS:

• Required Education: High school diploma or equivalent.
• Preferred Education: Associates Bachelors or Masters 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 facilitys 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.

Our Full-time benefit package offers the following:

• Competitive Salary
• Paid Time Off
• Paid Holidays (8 Total)
• Medical Dental & Vision Insurance
• FSA & HSA Plans
• Long-Term & Short-Term Disability
• Company Paid Life Insurance
• Supplemental Life Insurance
• Employee Assistance Program
• Employee Discount Program
• 401(k) Retirement Plan with Company Match
• Many employee-centered events throughout the year!

Hourly pay range: $31-50 Dependent on candidates current licensure and experience.

Required Experience:

IC