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…
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Full-time
high school, associate degree, bachelor degree, postgraduate degree
Posted 39d ago
Apply by Aug 4
~40 hrs/week
Responsibilities
The Utilization Specialist acts as a liaison between managed care organizations and clinical staff to monitor patient services and optimize reimbursement. They are responsible for conducting medical necessity reviews, managing the formal appeal process, and ensuring accurate documentation for continued stay criteria.
Requirements
Candidates must have a high school diploma, with a preference for degrees in social work, nursing, or related health fields. Clinical experience or at least two years of experience with the facility's population is required, along with relevant state licensure.
Full 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 equal employment opportunities to all applicants for employment regardless of an individual’s characteristics protected by applicable state, federal and local laws.
Rio Vista Behavioral Health provides state-of-the-art inpatient psychiatric and substance abuse services in the El Paso, Texas, area. We offer individualized planning and ongoing recovery support for adults age 18 and older and children ages 11-17. Our team is adept at serving high-acuity patients who may be struggling with symptoms of serious mental health concerns, such as trauma, mood disorders, anxiety, and psychosis. We’re also pleased to provide support for individuals in need of professional care for chemical dependency as a secondary concern.
Patients at Rio Vista Behavioral Health will have access to innovative holistic and evidence-based modalities, including cognitive-behavioral therapy (CBT), dialectical behavior therapy (DBT), mindfulness-based cognitive therapy, art therapy, and recreational therapy. This integrated approach offers a broad spectrum of therapeutic interventions that foster comprehensive healing of the mind, body, and spirit.
Offices: 1390 Northwestern Dr, El Paso, Texas 79912, US
How many Healthcare jobs are open in El Paso, TX right now?
There are currently 999 open healthcare positions in El Paso, TX listed on Clera. New openings are added daily as companies post roles.
Which companies are hiring for Healthcare roles in El Paso, TX?
Companies currently hiring include Tenet Healthcare, El Paso Children's Hospital, Becton, Dickinson and Company, Aiken Regional Medical Centers, CVS Health, among others. Browse the listings above to see every active employer.
Are there remote or hybrid Healthcare jobs in El Paso, TX?
Yes — 62 of the 999 open healthcare positions offer remote or hybrid work (32 remote, 30 hybrid).
How do I apply for Healthcare jobs in El Paso, TX?
Each listing links directly to the employer's application page. Apply early — fresh listings get the most recruiter attention in the first two weeks.