Utilization Specialist Job Responsibilities:

• 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.

OTHER FUNCTIONS:

· Perform other functions and tasks as assigned.

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.

Job Type: Full-time

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