Utilization Specialist

Purpose

Proactively monitor utilization of services for patients to optimize reimbursement for the facility.

Responsibilities

• Act as liaison between managed care organizations and the facility’s 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 facility leadership or corporate office.
• Conduct quality reviews for medical necessity and services provided.
• Facilitate peer‑review calls between the 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.

Qualifications

• 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 by the state.
  • CPR and de‑escalation and restraint certification required (training available upon hire and offered by the facility).
  • First aid may be required based on state or facility requirements.