What are the responsibilities and job description for the Utilization Specialist position at Acadia Behavioral Health (Pioneer Behavioral Health)?
Overview
PURPOSE STATEMENT:
Proactively monitor utilization of services for patients to optimize reimbursement for the facility.
Serenity Knolls is located in the San Geronimo Valley just 10 minutes West of Fairfax, has a new opening for an onsight Utilization Review Specialist , to join our team. Serenity Knolls is a 42 bed co-ed facility serving ages 18 and up. Included in the 42 bed capacity are 6 beds available for detox. Serenity Knolls is a 12 step based, social model residential treatment center. The Knolls uniquely combines the traditional social model of care with contemporary cognitive behavioral, psychodynamic and evidence based practice.
We are committed to fostering a diverse and inclusive workplace that reflects the communities we serve. We are an Equal Opportunity Employer and do not discriminate on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, disability, age, veteran status, or any other protected status under applicable law.
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.
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.
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