Utilization Review Specialist- Full Time

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.

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.