About this role
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.
RIVWDS
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.
Other facts
About RiverWoods Behavioral Health
Most people would rather hide from change than embrace it. When we do, unseen opportunities aren’t realized. Change is one of the most powerful tools you have as you go forward in life, if you embrace it.
Our counselors are trained in Positive Psychology which focuses more on strengths than on weaknesses, building the best things in life instead of repairing the worst, and paying attention to the things that contribute to human health instead of healing wounds and focusing on sickness. We also provide Cognitive Behavioral Therapy (CBT) and Acceptance and Commitment Therapy (ACT). All are evidence-based approaches found to be the most beneficial to healing.
What you'll do
- The Utilization Specialist will monitor service utilization for patients to optimize reimbursement and act as a liaison between managed care organizations and clinical staff. Responsibilities include conducting reviews of insurance plans, monitoring patient length of stay, and facilitating peer review calls.
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