Utilization Review Specialist

Utilization Review Specialist - Full Time

Location:

Cedar Crest Hospital & Residential Treatment Center

Proactively monitor utilization of services for patients and optimize reimbursement for the facility. Review for quality of services provided and medical necessity.

• 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.
• Inform clinical and medical staff of any specific concerns that would extend or restrict the length of stay of patients.
• Keep accurate record of all contact with external organizations and persons who have legitimate interest and legal access to information on the care of patients.
• Facilitate peer review calls between facility and external organizations.
• Act in coordination with the leadership team of the facility or corporate office to improve the quality of services provided within the organization.
• Assist the admissions department with pre-certifications of care.
• Initiate and complete the formal appeal process for denied admissions or continued stay.
• Provide ongoing support and training for staff on documentation or charting requirements, continued stay criteria and medical necessity updates.
• 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.

• Perform other functions and tasks as assigned.

Licensed LPN or RN, or Associate's Degree, Bachelor's Degree in Social Work, behavioral or mental health, nursing or other related health field;
Master's degree in social work, counseling, nursing or related health field preferred. 2+ years' experience with the population of the facility and previous experience in utilization management preferred.

Current licensure as an LPN or RN 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.

• Seniority level:
  Entry level
• Employment type:
  
  Full-time
• Job function:
  Other
• Industries:
  Mental Health Care