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RN or LPN Utilization Specialist

2 months ago

Ada, United States Rolling Hills Hospital Full time
Overview:

All candidates should make sure to read the following job description and information carefully before applying.

FT RN or LPN Utilization Specialist - M-F 8a-5p

Rolling Hills Hospital in Ada, OK,

At Rolling Hills, we specialize in providing exceptional care for adolescents, adults, and seniors struggling with mental health disorders and substance abuse issues. Our mission is to build a strong foundation for long-term recovery.

Our patients benefit from our decades of experience, our comprehensive spectrum of age-appropriate services, and our commitment to personalized care. At every step, our patients will receive clinically superior services delivered by dedicated professionals in an atmosphere of dignity and respect.

At Acadia Healthcare, we offer a comprehensive benefits package including medical, prescription drug plan, flexible spending accounts, health savings accounts, vision, dental, and voluntary short-term and long-term disability coverage. Additionally, our well-being programs encompass employee assistance programs, financial support, tuition reimbursement, and much more.

Responsibilities:

PURPOSE STATEMENT:

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

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.

AHRN