Utilization Specialist (100% onsite)

About the Role

We are seeking a full-time Utilization Specialist to proactively monitor utilization of services for patients to optimize reimbursement for the facility. Coastal Pines is a modern, purpose-built facility and a cornerstone of behavioral health care in Northeast Florida, designed to meet the growing demand for high-quality psychiatric services in the region. The 144-bed behavioral health hospital, located in St. Johns, will offer a full continuum of services including inpatient psychiatric care, Partial Hospitalization Program (PHP), Intensive Outpatient Program (IOP), and Electroconvulsive Therapy (ECT).

What We Offer

Our leaders are equipped with the tools, support, and benefits they need to thrive:

• Competitive compensation package including performance-based incentives
• Comprehensive medical, dental, and vision insurance
• 401(k) plan with company match through Acadia Healthcare
• Equity/stock-based incentive awards for long-term financial growth
• Generous paid time off including vacation, holidays, and sick days

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
• Perform other functions and tasks as assigned

Education & Experience

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 & 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.