LEAD UTILIZATION SPECIALIST

Overview

​PURPOSE STATEMENT: 

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

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.
• Evaluate the utilization program for compliance with regulations, policies and procedures.
• Provide staff management to including hiring, development, training, performance management and communication to ensure effective and efficient department operation.

oTHER FUNCTIONS:

Perform other functions and tasks as assigned

Qualifications

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Education/Experience/Skill Requirements:

• Associate's degree in nursing (LPN or RN) required. Bachelor's or Master’s degree in social work, behavioral or mental health, nursing or other related health field preferred.
• Two or more years' experience with the population of the facility and previous experience in utilization management preferred.

Licenses/Designations/Certifications:

• 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.

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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